Redefining parental identity: caregiving and schizophrenia

Unraveling Reactionary Care: The Experience of Mother-Caregivers of Adults with Severe Mental Disorders in Catalonia

In most Mediterranean countries, people diagnosed with severe mental disorders (SMDs) are typically cared for by the mother, causing a significant burden on people in this family role. Based on a broader mental health participatory action and qualitative research carried out in Catalonia (Spain) of 12 in-depth interviews and 3 focus groups, this article analyses the mother-caregivers' experience in the domestic space. The results show that patients and caregivers are engaged in a relationship of "nested dependencies", which create social isolation. This produces the conditions of "reactionary care", practices that limit the autonomy of those affected and that reproduce forms of disciplinary psychiatric institutions. We conclude that both institutional violence derived from economic rationality and that which stems from the gender mandate feed off each other into the domestic sphere. This research argues for placing care at the center of clinical practice and shows the need to consider the structural forces shaping it.

The Help-Seeking Experiences of Family and Friends Who Support Young People With Mental Health Issues: A Qualitative Study

Little has been documented of the journey that family and friends (F&F) undertake when supporting a young person aged 12-25 years struggling with mental illness. The experiences of family and friends were explored using an online qualitative survey (N = 58) and semi-structured interviews (n = 15). Recruitment was through a national youth mental health service Facebook page and website. An experiential thematic analysis was conducted focusing on participants' experiences and sense of their world.Strong feelings and challenging life circumstances made the context of help-seeking complicated. Despite following usual avenues for advice or support, F&F still came across professionals and a health/mental health system that compounded their distress. It was the simpler things that some professionals did that made their journey more bearable. Useful insights derived from the narratives allow service improvement recommendations such as reminding professionals of the multiplicity of stressors commonplace to families and the value of validation and acknowledgement.

Needs, challenges, and coping strategies among primary caregivers of schizophrenia patient: A systematic review & meta-synthesis

INTRODUCTION

Deinstitutionalization and rising psychiatric care in society have led to an increase in the role of caregivers of persons diagnosed with schizophrenia.

OBJECTIVE

The objective of this systematic review was to identify and synthesize qualitative research findings that explored the needs, challenges, and coping strategies among the primary caregivers of a schizophrenia patient.

METHODOLOGY

The electronic databases namely PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Scopus, Web of Science, ProQuest, and ClinicalKey were searched to identify relevant articles published from 2005 to October 2021. The quality of the included articles was independently appraised by two reviewers using Walsh and Downe criteria and was analysed thematically. The meta-synthesis was modelled on Lucas framework.

RESULTS

The richness of information across 38 papers involving 543 participants was noteworthy. The needs of the primary caregivers were rehabilitation and vocational centre, information and education, self-help groups, augmented healthcare services, and communication and collaboration. The challenges reported were treatment expenses, bizarre beliefs, self and other directed harm and violence, therapeutic noncompliance, onerous caregiving task, crumbling family relations, misconception and discrimination, and self-stigmatization. The coping strategies adopted were problem-focused coping, emotional coping, behavioural coping, coping through social support, religious coping and cognitive reappraisal.

CONCLUSION

The primary caregivers provide unparalleled service to the health system and for the patient. The healthcare providers need to give undue attention to the unmet needs and challenges of the caregivers, which would benefit the health system by enabling the caregivers in providing long-term care for the schizophrenic.

Nursing Science, Mental Illness, and the Family: A Conceptual Framework to Break the Cycle of Suffering

Mental illness is an epidemic in the United States, and there is a gap in care due to minimal integrated programs and transitional community resources. This paper reports the development of a conceptual framework to identify challenges facing families living with mental illness and the integral role nursing plays to positively impact health. An inductive, bottom-up approach was used to develop the Nursing Science, Mental Illness and Family model. Concepts clustered around family health, cycle of suffering, improving outcomes, healthcare policy, and nursing science. Successful, goal-directed interprofessional collaborations are essential for individual-, family-, and system-level interventions to be effective.

Just Like Any Other Family? Everyday Life Experiences of Mothers of Adults with Severe Mental Illness in Sweden

This study explores experiences of mothers in Sweden who care for their adult children suffering from severe mental illness. Using 15 interviews with mothers from 40 to 80 years old, the article examines how predominant professional knowledge and sanism constructs the mothers and their children as deviant and what counterstrategies the mothers develop as a response to these experiences of discrimination. The findings show that the mothers' experiences are characterized by endless confrontations with negative attitudes and comments that have forced them to go through painful and prolonged processes of self-accusations for not having given enough love, care, support and help in different stages of their children's life. But the mothers' experiences also reveal important aspects of changes over the life span. As the mothers are ageing, the relationship between them and their children becomes more reciprocal and the ill child may even take the role as family carer.

A Qualitative Systematic Review of Caregivers' Experiences of Caring for Family Diagnosed with Schizophrenia

Objective: To synthesise qualitative research that explored caregivers' experiences of caring for family diagnosed with schizophrenia.Methods: Electronic databases including PsycINFO, PubMed, CINAHL and Scopus were searched to identify relevant journal articles published from 2000 to March 2019. Quality was assessed and thematic synthesis of the qualitative research evidence undertaken. Papers were screened and independently appraised by two reviewers using The Critical Appraisal Skills Programme (CASP) for Qualitative Studies Checklist. The review was guided by Thomas and Harden's framework for thematic synthesis of qualitative research evidence.Results: The breadth of information across the 43 papers was noteworthy. Review of the findings noted that almost all of what was discussed fell into three broad themes: the 'feelings' of the caregiver towards their role, the patient and others, including the health system; the 'impacts' of the diagnosis and their caregiving role on the caregiver; and the 'needs' of the caregiver to improve the patient's quality of life and thereby the caregiver's quality of life. Within needs also came recommendations for future changes.Conclusion: Studies have shown that the caregiving process is a complex one, with both negative and positive emotional reactions, societal barriers, such as stigma and isolation, and unmet needs, such as timely, relevant and helpful information. Meeting the needs identified by caregivers has the capacity to address the impacts of the illness and caregiving and thereby reduce the negative feelings associated with the caregiver role.

Relational trajectories in families with parental mental illness: a grounded theory approach

BACKGROUND

Adult children of parents with mental illness experience a myriad of complex emotions as they attempt to make meaning of the lived experiences of their parents. A crucial time for adult children is emerging adulthood, a time when they move away from their family of origin and establish their own identity and independence. Despite existing research that provides a static description of adult children's lived experiences, the literature lacks an explanatory theory about the dynamic, relational processes that occur as adult children progress from one life stage to the next.

METHODS

The current study aimed to develop an explanatory theory of the relational trajectory that adult children might experience as they course through adulthood and parenthood over time. Semistructured interviews using grounded theory analysis were conducted with 10 adult children aged between 27 and 51 years old.

RESULTS

Three key phases within the Relational Trajectory Model (RTM) were identified: (i) confusion, (ii) contemplation, and (iii) reconciliation. By reflecting on their own parenting role, adult children were able to reach an evolved parental identity, with the majority of participants also making relationship reparations with their parents with mental illness. Parallels are drawn to theories of identity and intergenerational family systems to further explain and substantiate the processes encompassed within the RTM.

CONCLUSION

Generating an explanatory theory serves as a potential guide for mental health professionals working with families with parental mental illness, by drawing attention to the intricacies of familial relationships and interpersonal ties.

The Paths to Negative and Positive Experiences of Informal Caregiving in Severe Mental Illness: A Study of Explanatory Models

The experience of caregiving in severe mental illness is a valuable concept for research and clinical practice as it can provide access to the idiosyncratic assessment of negative and positive dimensions of informal caregiving, thus allowing the design of interventions focused on reducing risk factors and promoting protective factors. This study was aimed at testing explanatory models of negative and positive experiences of caregiving considering the role of the caregiver’s perceptions of difficulties, satisfaction, and coping. A convenience sample of 159 informal caregivers of patients with schizophrenia was used in this study. Different variables were considered: (1) perception of difficulties (Caregiver’s Assessment of Difficulties Index); (2) perception of satisfaction (Caregiver’s Assessment of Satisfaction Index); (3) perception of coping (Caregiver’s Assessment of Managing Index); and (4) the experience of caregiving (Experience of Caregiving Inventory). Using structural equation modeling, the results revealed the following: (1) the perception of difficulties and of satisfaction coexist; (2) the negative experiences of caregiving are predominantly explained by the perception of difficulties and of coping with stress; and (3) the positive experiences of caregiving are mainly explained by the perception of sources of intrapersonal satisfaction, while the perception of coping does not have robust predictive value.

The Parents' Self-Stigma Scale: Development, Factor Analysis, Reliability, and Validity

For parents of children with a mental health disorder, self-stigma can negatively impact their self-esteem and empowerment. Although measures of self-stigma exist, these have not been created in consultation with parents of children with a mental health disorder. Thus, the aim of this study was to construct a new scale based on parents' experiences and developed in partnership with parents through participatory action research (PAR). Draft items that reflect parents' self-stigmas were drawn from qualitative research. A PAR group further developed these items for conceptual and experiential representativeness, and wording suitability and interpretability. With data from 424 parents of children with a mental health disorder, factor analyses indicated three factors: self-blame, self-shame, and bad-parent self-beliefs. These factors were negatively correlated with self-esteem and empowerment. Internal consistencies were acceptable. In sum, parent self-stigma is best operationalised as including self-blame, self-shame, and bad-parent self-beliefs. A valid, PAR-informed measure is provided to promote consistent, authentic, and sensitive measurement of these components.

Understanding caregiver burden from a long-term perspective: The Banyan model of caregiver experiences

PURPOSE

A multiphase model for experiences of family members of persons with mental illness that considers both positive and negative aspects is proposed.

DESIGN AND METHODS

Mixed methods (semistructured interviews, life history timelines, focus group discussions, and the Experience of Caregiving Inventory) were used with caregivers accessing outpatient services of a nongovernmental organization in urban and rural locations around Chennai, India.

FINDINGS

Based on our results, we constructed a multiphase model, which we named The Banyan model of caregiver experiences. The phases are (1) manifestation of symptoms, (2) seeking help, (3) helplessness and attribution, (4) relative control and insight, (5) loss and worries, and (6) finding new meaning.

PRACTICAL IMPLICATIONS

Our multiphase model allows us to identify in more detail the needs of caregivers at various stages.

Adaptation of the Utrecht-Management of Identity Commitments Scale (U-MICS) to the measurement of the parental identity domain

The present studies examined the psychometric properties of the Utrecht-Management of Identity Commitments Scale (U-MICS) adapted to the measurement of identity formation in the parental identity domain. As the parental identity domain has only been studied within the neo-Eriksonian approach to a very limited extent, the aim of these studies was to prepare a short, valid and reliable tool for the measurement of parental identity in order to fill this gap. The associations of commitment, in-depth exploration and reconsideration of commitment in the parental domain with well-being and with other identity constructs were analyzed. The results showed that parental identity formation is associated with mothers' satisfaction with life and trait anxiety and with identity formation in other areas as well. The initial results suggest that the adapted version of the U-MICS is a valid and reliable measure that can be used in future studies on parental identity formation.

Mothers' Decisions to Disclose or Conceal Their Child's Mental Health Disorder

Parents of children with mental health disorders are often faced with the dilemma of disclosing or concealing their child's disorder. These decisions have important implications for both child and parent. Our aim is to describe mothers' experiences with the disclosure dilemma; specifically, we describe what is disclosed (or concealed), how, and why, as well as the consequences of these decisions. Data from interviews with 11 mothers of children (aged 5-13 years) with mental health disorders, and a participatory action research group (four mothers) were thematically analyzed. Mothers selectively disclosed (and concealed) to protect and advocate for their child. Their decisions were often influenced by, or were a reactance to, others' opinions, with mothers not only avoiding, but also defending against stigma, and exercising their right to privacy. Despite anticipating negative feedback, mothers more often experienced empathy and support following disclosure. Recommendations are made for developing mothers' confidence in disclosing.

Caring for an intimate stranger: parenting a child with psychosis

WHAT IS KNOWN ON THE SUBJECT

The care of an adult son or daughter with psychosis is filled with overwhelming demands caused by the symptomatology and illness exacerbations. Parents display disenfranchised grief over multiple losses and report increased levels of emotional burden. Most studies use quantitative methods and rely on pre-existing theoretical frameworks to investigate, through psychometric measures, the effects of being a carer. Meaning attributions to the disorder, and changes in parent-child relations over time, are poorly understood.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

This hermeneutic phenomenological study illuminates the subjective experience of parenting a son or daughter with psychosis, as it is lived and described by parents of young adults with psychosis. Findings suggest that the parents' perceptions of their child changes over the course of the disorder, leading to a redefinition of the parent-child relationship, causing alternations in attachment. Findings illuminate the parents' profound guilt over having contributed or not prevented the disorder, over not being 'good' parents and feeling ambivalent towards an 'intimate stranger.' Guilt is compensated by absolute dedication to the son or daughter's care, at the expense of their own well-being.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Interventions for parents must be available as soon as possible, both during hospitalization and after discharge. Professionals should provide a therapeutic space, where parents could express intimate thoughts and feelings, address guilt, fear and resentment issues, be assisted in their parenting role as well as in the reconstruction of a sense of self and self-esteem. Professionals are invited to facilitate illness acceptance, provide accurate information, assist parents to redefine their relationship to the child and facilitate the integration of the traumatic experience into their personal and family narrative. Professionals must develop in depth awareness of their biases and attitudes, have an ongoing training on how to respond to the parents' needs, facilitate therapeutic change and accompany families through the course of their adult child's illness trajectory.

ABSTRACT

Introduction Children who are diagnosed with psychosis often rely on their parents for prolonged care. The impact of such care is partially understood as most studies use quantitative methods and pre-existing theoretical frameworks that limit their investigation to emotional burden, and emotional responses. Aim Explore the parents' lived experience of caring for a child with psychosis. Method A hermeneutic phenomenological design was used with a sample of 16 parents of children with psychotic disorders who were hospitalized or attended the outpatient clinic of a large psychiatric Greek hospital. Results Identified themes were as follows: (i) the psychosis experience, (ii) redefinition of the parent-child relationship over the course of the disorder and (iii) challenges of parenting a child with psychosis. Discussion 'Caring for an intimate stranger' reflects the parents' overall experience, involving changes in the parent-child relationship, ambivalence towards caretaking and profound guilt, compensated by self-sacrifice parenting practices.

IMPLICATIONS FOR PRACTICE

Findings highlight the necessity to train mental health professionals to provide individualized information; facilitate family communication; address the parents' guilt, ambivalence, meaning attributions that compromise adjustment; and support them through the challenges of parenting a son or daughter with psychosis.

Personal and relational empowerment: a framework for family recovery

Purpose

Caring for a person with a substance use disorder (SUD) and/or mental health disorder (MHD) represents a significant burden for family members. The features of “carers/family members” experiences reflect trauma signatures. Consequently, working through this trauma for carers corresponds with psychological recovery, empowerment processes and intrapersonal/interpersonal needs. The purpose of this paper is to outline a framework called the “personal and relational empowerment (PRE)” framework which enables family support practitioners to help family members to be able to take control of their own lives, develop meaningful relationships and live purposeful and fulfilling lives, regardless of whether the person with the SUD and/or MHD is in recovery or not.

Design/methodology/approach

This paper critically reviews existing frameworks for carer recovery, through a systematic literature search, and proposes a “PRE” alternative to redress the shortfalls in these existing frameworks.

Findings

The PRE framework takes a multi-level needs-based approach to understand carer recovery. This framework links the concepts – psychological recovery, empowerment processes and intrapersonal/interpersonal needs.

Practical implications

The PRE framework recognises the importance of recovery support practitioners being able to balance the immediate carer crisis intervention needs responses with personal growth and well-being supporting interventions.

Originality/value

The PRE framework of family recovery attempts to answer the need to broaden the focus on the family journey to better reflect the principles and practices of contemporary SUD and/or MHD recovery-based support.

'Canaries in the mine'. Parents of adult children with schizophrenia: An integrative review of the literature

The purpose of this integrative review was to evaluate the current state of knowledge of parents who have adult children diagnosed with schizophrenia and their relationship with mental health professionals. Findings indicated that parents (primarily mothers) believed they intuitively knew when their adult children were becoming unwell and that they doggedly pursued connections with mental health care providers. Five themes were evident in the literature: trusting your instincts, feeling dismissed and devalued, making connections and making concessions, living with distress and sorrow, and becoming your own health-care provider. The implications of the findings on mental health nursing practice indicate that professional family relationships were not ideal, and that parents wanted to improve these relationships. Parents wanted health-care professionals to respond to their requests for help for both their children and for themselves, and wanted to be able to help the mental health team to help their adult children.

Knowing What to Do and Being Able to Do It: Influences on Parent Choice and Use of Practices to Support Young People Living with Mental Illness

A parent's response to a young person's mental illness can influence their recovery and wellbeing. Many parents devote considerable time and energy to supporting a young person experiencing mental illness and engage in numerous different practices to do so. Yet little is known about why parents use particular practices. This article explores this question through qualitative analysis of parent perspectives. Interviews with 32 parents of young people living with mental illness were analysed using constant comparative analysis. Findings suggest that parents' choice of and ability to carry out particular practices are shaped by: their knowledge and beliefs; their personal resources and constraints; and their social and service networks. Further, parents took active measures to optimize these influences. By understanding the complexity of their own potential influence on both knowing what to do and being able to do it, health professionals can better enable parents to support young adults experiencing mental illness.

A Dynamic Cycle of Familial Mental Illness

In this paper, we present A Dynamic Cycle of Familial Mental Illness; an innovative framework, which considers family members' experiences and responses to mental illness. There is an acknowledged discourse noting parental experiences of mental illness alongside a growing body of knowledge acknowledging children's needs while living with parental mental illness. However, there is a paucity of literature that makes reference to the concept of familial mental illness and the cyclic interface of parental and child distress and symptoms. The model is supported by published research studies from several differing disciplines to demonstrate the relationship between parent and child experiences and to synthesise the published short- and longer-term possible impact of familial mental illness. An extensive search of the literature using recognised search engines, keywords and phrases has been undertaken, to generate an appropriate literature base for this work. This literature demonstrates how a child's possible emotional distancing as a response to parental mental illness could increase parental distress. A Dynamic Cycle of Familial Mental Illness adopts the underpinning philosophy of a Stress Vulnerability Model of Mental Illness, which assumes that predisposing factors and increased stress for a parent may have possible links to exacerbation of parental mental distress and symptomology. We advocate for further research of familial mental illness, and argue for a family approach to mental health assessment and treatment in mainstream health and social care sectors.

Family caregiving for adults with schizophrenia and diabetes mellitus

Diabetes mellitus (DM) is common among those with schizophrenia, but little is known about family members' roles in the care of relatives who have both schizophrenia and DM. The purpose of this descriptive correlational study was to examine DM knowledge and caregiver burden among 27 family caregivers of people with schizophrenia and DM. Findings indicate that DM knowledge was low. Objective caregiver burden was highest for providing assistance with daily living activities. Subjective burden was highest for preventing the care recipient from keeping people awake at night and dealing with the care recipient's non-adherence to DM care. Family caregivers are in need of education and support in the caregiving role.

Ajustamento familiar após o surgimento da esquizofrenia

Considera-se que, quando ocorre o primeiro episódio da esquizofrenia, a vida familiar é interrompida e a sua trajetória de vida pode ser modificada. Em vista disso, o objetivo deste trabalho foi conhecer a trajetória de famílias nos primeiros cinco anos de convivência com a doença mental, identificando o seu processo de ajustamento. A pesquisa está fundamentada no Interacionismo Simbólico. Foram realizadas entrevistas com 23 familiares de 21 portadores de esquizofrenia. A análise foi realizada visando à determinação de uma linha do tempo, que permitiu descrever o processo de ajustamento familiar através de três momentos: Percebendo a Mudança, Diagnóstico e Início do Tratamento, e Seguindo em Frente. Conclui-se que todas as fases apresentadas neste projeto são ricas e podem ser mais exploradas.

A interação entre pessoas com esquizofrenia e familiares interfere na adesão medicamentosa?

OBJETIVO: Identificar, na perspectiva da pessoa com esquizofrenia e de seu familiar, como ocorre a interação paciente-familiar relacionada à adesão ao tratamento medicamentoso. MÉTODOS: Estudo de abordagem qualitativa, com referencial metodológico da Teoria Fundamentada nos Dados e pressupostos do Interacionismo Simbólico. Participaram do estudo 36 pessoas com esquizofrenia em tratamento ambulatorial e 36 familiares. Para obtenção dos dados, usadas a entrevista gravada e a observação. RESULTADOS: Os depoimentos obtidos revelaram que familiares podem fornecer apoio e motivação, propiciando a adesão do paciente ao tratamento, podendo também incentivá-lo a não aderir à farmacoterapia. Destacaram-se ainda a influência da sobrecarga e o despreparo do familiar cuidador sobre a qualidade dos cuidados prestados. CONCLUSÃO: Profissionais da saúde podem intervir junto aos familiares, encorajando as interações que colaboram com o sucesso do tratamento e incentivando-os a modificar as interações que o comprometem.

Expressões utilizadas por familiares ao relatarem experiências de conviver com o adoecimento mental

OBJETIVO: Identificar as expressões usadas por familiares para descrever a experiência de conviver com o adoecimento mental. MÉTODOS: Tratase de pesquisa que realizou análise dos relatos de familiares por meio do software Analyse Lexicale par Contexte d'um Ensemble de Segments de Texte (ALCESTE), contendo metodologia de análise de dados qualitativos que se adapta a qualquer domínio de investigação, em que se pretenda tratar material textual. RESULTADOS: A análise realizada pelo ALCESTE forneceu quatro classes agrupadas duas a duas: Classe 2 -- início da doença e Classe 4 -- início do tratamento; Classe 1 -- convivência e Classe 3 - cotidiano. CONCLUSÃO: Os momentos descritos pelos familiares foram identificados por expressões, palavras e termos usados pelos mesmos em suas narrações. A principal contribuição deste estudo foi trazer a linguagem dos familiares para descrever os momentos do adoecimento por meio de uma metodologia de análise mais distante do pesquisador.

Perceptions and needs of parents during a young adult's first psychiatric hospitalization: "we're all on this little island and we're going to drown real soon"

A young person's first psychiatric hospitalization can present a crisis for the family. This initial contact with the mental health care system and health care providers, whether positive or negative, has the potential to set the foundation for all future interactions. The purpose of this study was to examine the impact of a young person's first hospitalization on his or her parents and to determine the parents' perspectives on their own emotional and practical support needs. Ten parents (nine mothers and one father) of a young person aged 18 to 25 were recruited through local support groups and by snowball sampling. Based on Aguilera and Messick's (1986) crisis theory, participants were asked about their perception of the event, coping methods they used, and support systems they engaged while their adult child was hospitalized. Six themes were identified: feeling relief about receiving a diagnosis; shock and disbelief associated with the diagnosis of a mental illness; isolation associated with the stigma of mental illness; feeling excluded during the discharge process; and grieving for the loss associated with an altered future. The results revealed that participants received their support from family, friends, and support groups and did not find mental health care providers to be helpful or supportive. The participants provided recommendations for those who work with families experiencing the crisis of a first psychiatric hospitalization.

Being there for another with a serious mental illness

In this article I describe the unique caring and caretaking relationship between a mentally ill person and the nonprofessional caretaker in his or her life. Stressing the perspective of the caretaker, I call this relationship "being there" for the mentally ill person. I collected the data through in-depth interviews and used a descriptive phenomenological approach to unveil the general structure of the experience. Eight constituents emerged as central to the general structure of this experience: (a) accepting the changed other and grieving the loss of who the other once was; (b) taking action in challenging circumstances; (c) recognizing the ongoing, never-ending, and sometimes unpredictable nature of the experience; (d) feeling isolated; (e) having ambiguity of the heart; (f) experiencing the tension of waiting; (g) knowing the other well; and (h) caring for the other. Knowledge gained from the study findings will help health care professionals understand and support people who are in this experience from a more caring paradigm.

A fine line to walk: case managers' perspectives on sharing information with families

In the United States, sharing information with families in health care involves competing demands between clients' rights to confidentiality and families' wishes to know. In this article, I explore how community mental health providers share information with families of clients with severe mental illness. I interviewed 24 case managers in assertive community treatment programs. Results show that case managers share information with families to attain treatment goals rather than to support families in providing care. Case managers respect clients' confidentiality and do not release information without client consent. However, the absence of client consent posts an ethical dilemma when families provide helpful information for clients' treatment. Case managers find themselves walking a fine line between adhering to confidentiality guidelines and working for the clients' best interests. The findings suggest the need to expand confidentiality laws to the exchange of information and to develop guidelines for working with families in community settings.

Challenging Roles: Insights Into Issues for Men Caring for Family Members With Mental Illness

Assumptions informing expectations of caring may not reflect the diversity of circumstances in which informal care is provided, and scant attention has been given to the experiences of men providing care to family members. This study reports on qualitative findings from a study that explored these issues among rural men caring for partners or children with a range of mental illnesses. The findings suggest that the primary relationship between carers and care recipients influences the ways in which the men understand and practice their caring roles. Fathers consistently described proactive approaches to caring and were strongly focused on managing the illness condition. There was some complementarity between parenting and caring roles that is likely to explain why they reported a high use of, and satisfaction with, mental health services. Husbands tended to take reactive approaches to caring in which they were more concerned with managing situations that were associated with their partners' illnesses. Husbands reported limited contact with treatment and support services and perceived them as inappropriate to their circumstances. All of the men were presented with complex tensions in their caring roles, and the men's accounts of caring that are presented offer useful insight into the contexts in which men are increasingly taking on caring roles in families and inform efforts to support men in this capacity.

Mulheres, loucura e cuidado: a condição da mulher na provisão e demanda por cuidados em saúde mental

As políticas públicas brasileiras em saúde mental incentivam, atualmente, a criação de serviços extra-hospitalares e, como resultado, o papel da família, especialmente da mulher, no cuidado informal ao portador de sofrimento mental ganha a cada dia maior relevância. Embora considerada como fundamental na prestação de cuidados no meio familiar, a mulher também adoece e torna-se, deste modo, alvo de cuidados das equipes de saúde mental. A partir dessa consideração, este artigo apresenta uma revisão sobre a condição da mulher que recebe e provê cuidados em saúde mental. O artigo aborda, inicialmente, estudos que discutem a relação entre mulher e loucura, partindo de registros da Idade Antiga até estudos referentes ao início do Século XX no Brasil. Em seguida, enfoca a mulher enquanto principal prestadora de cuidados informais, em âmbito doméstico, ao portador de sofrimento mental, a partir de estudos que tratam do impacto dessa função na vida familiar. Por fim, destaca literatura sobre as necessidades específicas da mulher que demanda cuidados em saúde mental, notadamente aquela que tem filhos menores, dependentes de cuidado. Reconhecer as especificidades da condição da mulher pode auxiliar no desenvolvimento de novas formas de cuidar, que envolvam a família não apenas como fonte de informações sobre a paciente, mas como grupo que também necessita da intervenção profissional. Mulheres com filhos pequenos e diagnosticadas com transtorno mental severo demandam suporte profissional, especialmente se houver indicação de internação ou necessidade de cuidado contínuo.

Relationship-based support for women living with serious mental illness

Relationships are critical to a woman's growth and development, yet when living with serious mental illness, developing and nurturing connections can be challenging. This qualitative study explored the nature and quality of support provided within relationships for 14 women with schizophrenia. Families were key supporters. Female friends with mental illness often provided a meaningful source of connection for participants. Problematic relationships, losses over time, and living in poverty were among the barriers to receiving needed support. Participants conveyed a sense of wanting relational reciprocity as they talked about their relationships and place within the community.

Tactful monitoring: how thai caregivers manage their relative with schizophrenia at home

Approximately 343,680 individuals in Thailand suffering from schizophrenia are cared for at home by relatives, most of whom have a little knowledge of the disease; therefore they're left to develop their own strategies of care. Data were collected by in-depth interviews and observation involving 17 caregivers of relatives diagnosed with schizophrenia. Data were analyzed using the constant-comparative method of grounded theory. Caregivers' chief concern was avoiding psychotic episodes. They do this through a process we call "tactful monitoring," which includes the co-variables "unobtrusive observation" and strategies for calming. Caregivers follow a trajectory that leads them to a state of exhaustion, tired and sad, and fearful about the future care of their loved one. Findings from this study led the authors to conclude that in Thailand, caregivers were able to develop creative ways of tending to their relatives with schizophrenia at home, but not without significant cost to themselves. Limited provision for caregiver education and respite exists. If education and increased respite care were instituted, caregivers could benefit, and patients might avoid expensive inpatient visits.

Theoretical sampling and category development in grounded theory

Theoretical sampling is a hallmark of grounded theory methodology, and yet there is little guidance available for researchers on how to implement this process. A review of recently published grounded theory studies in Qualitative Health Research revealed that researchers often indicate that they use theoretical sampling to choose new participants, to modify interview guides, or to add data sources as a study progresses, but few describe how theoretical sampling is implemented in response to emergent findings. In this article, two issues that arose relative to theoretical sampling in an ongoing grounded theory study are discussed. A theoretical sampling guide that was developed by the authors' research team to facilitate systematic decision making and to enhance the audit trail relative to theoretical sampling is described, and an example of how the guide was used to develop a category is presented.

Mastery, burden, and areas of concern among family caregivers of mentally ill persons

In an era of limited resources for mental health care, family interventions need to target areas where they are responsive to families' expressed needs. Although family burden has been documented, less is known about the areas of concern that families feel they need direct assistance with, to be effective caregivers. Telephone interviews were conducted with 30 family members of mentally ill relatives. Burden, sense of mastery, and contexts of caregiving were assessed. Open-ended questions elicited further understandings of caregiving concerns. The most frequently identified burden was "worry about the future." The greatest concern was "dealing with sadness and grief." Recommendations for assessing family concerns are presented.

Care: giving, receiving and meaning in the context of mental illness

Understanding the dynamics of caregiving is essential to providing effective support to individuals and families living with serious mental illnesses. Yet, research in this area has typically explored caregiving without consulting mentally ill people. This paper adds this overlooked viewpoint by exploring the experience of care relationships by people diagnosed with schizophrenia. A secondary analysis of interview data from 21 individuals reveals that relevant dimensions of care relationships include: providers of care; types of care received; self-care; contested practices in care; negotiating practices; recipients of care; and types of care provided to other people. Addressing care within this broader conceptualization can contribute to developing interventions for individuals and families that more fully recognize the potential for people with mental illnesses to be active participants in care relationships.

Adapt or adopt: developing and transgressing the methodological boundaries of grounded theory

AIMS

While acknowledging that there is an existing debate regarding the nature of grounded theory, the aim of this paper is to highlight a number of common and key areas/issues where adaptation/adoption of Glaserian grounded theory in nursing-related studies often occurs. These issues are: the differences between conceptual description and conceptual theory; beginning the study with a 'general wonderment' or a more defined research question; establishing the credibility of the theory; identifying a basic psycho-social process and emerging vs. forcing.

BACKGROUND

Since the development and introduction of grounded theory in 1967, the number of studies, in a wide range of disciplines including nursing, that purport to be using a grounded theory method has grown enormously. While Glaser and Strauss acknowledged then that it was entirely appropriate for the methodology to evolve and develop, some of the studies that claim to be based on grounded theory methodology share little methodological similarity, and at times, bear only a passing resemblance to Glaserian grounded theory.

DISCUSSION

Some methodological transgressions in papers that purport to be grounded theory studies are such that it would be inaccurate to term the resulting method grounded theory at all. Instead such studies are more accurately thought of as a form of qualitative data analysis. Such transgressions include a study that has no evidence of conceptualization; one that does not identify a basic psycho-social process; and one that moves from 'emerging' to 'forcing'. Other methodological adaptations of grounded theory, such as beginning the study with more than a general wonderment and broadening the approach to establishing the credibility of the theory, are more in keeping with Glaser and Strauss' position on the evolution of the method. In such cases, it is necessary to distinguish such methods from 'pure' Glaserian grounded theory, and it would be prudent and methodologically accurate to describe the resulting method as 'modified' grounded theory.

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