Communal normalization in an online self-help group for adolescents with a mentally ill parent

Children of parents with a mental illness - stigma questionnaire: validation and revision

Introduction

Mental disorders are often stigmatized in society. The stigma of mental illness affects people with a mental illness themselves as well as their family members-a phenomenon called stigma by association (SBA). Children of parents with a mental illness (COPMI) are a particular vulnerable group for SBA. In our systematic review, experienced SBA, anticipated SBA, affiliate SBA, and structural discrimination were identified as relevant stigma dimensions for children of parents with a mental illness. To assess SBA in adolescents who grow up with a parent with a mental illness, the COPMI-SQ was developed.

Methods

N = 930 adolescents completed the study. Of those, N = 380 adolescents (sample 1; 72.6% female, mean age 17.12 (SD = 2.01) years) reported growing up with at least one parent with a mental illness. Using confirmatory (CFA) and exploratory factor analyses (EFA) as well as standard item and reliability analyses, we analyzed and revised the COPMI-SQ in the first sample. To validate the factorial structure of the revised COPMI-SQ, CFA was also conducted in the independent sample of the other N = 550 adolescents (sample 2; 80.0% female, mean age 16.36 (SD = 1.98) years) who reported not growing up with a parent with a mental illness. To test four measurement invariance, a multiple-group CFA was conducted in the combined sample of adolescents who reported growing up with and without a parent with a mental illness (sample 1 and sample 2).

Results

CFA in sample 1 resulted in an inadequate model fit for the theoretically assumed four-factor structure (CFI = .687; RMSEA = .064 (90% CI = .062-.066); SRMR = .092; AIC = 229 155.63). Following EFA and item and reliability analyses in sample 1, the COPMI-SQ was reduced to four scales ("Experienced SBA," "Affiliate SBA," "Shame," and "Anticipated SBA") and two additional screening scales ("Healthcare" and "Social support"). To facilitate questionnaire use, only the three best items were retained in each scale, reducing the total item number to 12 plus five additional screener items. CFA in sample 2 also resulted in an inadequate model fit for the theoretically assumed four factor structure (CFI = .667; RMSEA = .065 (90% CI = .063-.066); SRMR = .101; AIC = 335 651.99). In comparison, the final version of the COPMI-SQ-r showed the best model fit (CFI = .945; RMSEA = .062 (90% CI = .052-.072); SRMR = .049; AIC = 60 008.05). In the multiple-group CFA (sample 1 and sample 2), metric invariance was established (χ2 (208) = 481.58, p < .001; CFI = .939; RMSEA = .053 (90% CI = .047-.059); SRMR = .056). In sample 2, internal consistency was found to be good for the total scale (α = .84) and almost acceptable to almost good for the subscales (α = .64 to.78).

Discussion

The revised version of the COPMI-SQ (COPMI-SQ-r) is a reliable and economic questionnaire to assess SBA in adolescents who grow up with a parent with a mental illness. The COPMI-SQ-r can be used to help develop and evaluate anti-stigma and general interventions for affected adolescents.

Resilience in children of parents with mental illness, alcohol or substance misuse-An integrative review

AIM

The aim of this integrative review was to investigate how resilience has been researched and explore experiences of resilience, in children of parents with mental illness or alcohol or substance misuse.

DESIGN

An integrative review.

METHOD

The search included three major electronic databases, PubMed, Scopus and PsycINFO with the aim of identifying peer-reviewed studies where the concept of resilience was explored as resilience, coping, adaptation or protective factors.

RESULTS

Out of 4016 studies, 14 were included after meeting predetermined criteria and methodological quality evaluation. The findings are presented in five categories: characteristics of the studies, operationalization and interpretation of resilience, individual resources, family resources and resources outside the family.

PATIENT OR PUBLIC CONTRIBUTION

Resilience in children of parents with mental illness or substance misuse refers to coping strategies, protective factors and absence of symptoms or risk behaviour despite being exposed to risk. We suggest a three-level approach for mapping of resilience resources in the target group: the individual level, family level and outside of the family that includes both non-professionals and professionals. The use of disengagement or avoidance strategies implies poor resilience but may be necessary in absence of support, as acts of self-preservation during chaotic periods or harmful situations.

Women and shame: narratives of recovery from alcohol dependence

OBJECTIVE

Existing literature indicates distinct pathways and the key role of shame and stigma into alcohol dependence (AD) and recovery for women. Internationally, there is a paucity of research exploring these factors from women's perspectives.

METHODS AND MEASURES

Taking a critical realist epistemological position, unstructured life story interviews were analysed via narrative analysis to explore how seven women from the UK, storied shame in their recovery from AD.

RESULTS

Shame followed a common trajectory across participants' stories, appearing as a reoccurring factor throughout AD and recovery. Participants narrated shame as gendered, contributing to a loss of personal control in defining a valued personal identity. Drinking began as a shame-management strategy but evolved into a source of shame, compounded by fears of being labelled an 'alcoholic woman'. Recovery involved reclaiming the self through de-shaming a shame-based identity and developing a positive, non-drinking identity. By evaluating 'shaming' recovery frameworks, sharing stories and reconstructing their own, participants were able to work through shame, resist pathologising identity labels and internalise esteemed 'sober' identities.

CONCLUSION

This research provides important insights into the intersection between shame, identity, gender and culture in women's recovery from AD. Implications for clinical practice, future research and policy are considered.

Children as next of kin's experiences, practices, and voice in everyday life: a systematic review of studies with Norwegian data (2010-2022)

Aims: This systematic review aims to identify and describe how children of parents with mental illness, substance dependence, or severe physical illness/injury, experience and practise their everyday life. Methods: The review followed the four stepwise recommendations of Harden and colleagues when including quantitative and qualitative studies on peoples' experiences and views. In all, 23 studies with data from Norway (2010-2022) have been included. Brown and Clark's thematic analysis was applied. Results: Three themes were constructed from the reviewed articles: (a) Children practice their relational agency by actively doing practical tasks, occasionally jobs to maintain family economy, and organising fun activities with the ill parent. (b) Emotional ambivalence when their own needs were set aside in favour of the parents. They loved their parents but also felt guilt, anger, disappointment, shame, fear of inheriting the illness and longed for a 'normal' everyday life. (c) Supportive contextual factors were, for example, at least one significant adult recognising them, participating in leisure activities, socialising with friends, and talking with other peers who shared similar experiences as next of kin. Obstructive factors were lack of information and recognition as well as silence and lack of dialogue within the family and/or health professional. Conclusions: There is a strong need for more knowledge and competence on the situation and needs of these children when it comes to professionals, parents and the public. Public health initiatives are needed to honour their agency and recognise their contributions in present time to prevent psychosocial problems later in life.

Support needs and experiences of young people living in families with mental illness

INTRODUCTION

Children and adolescents living in families affected by mental illness are at elevated risk of developing mental health problems. A range of interventions have been designed to help these young people; however, the effectiveness of these programs is, in some cases, mixed. Our aim was to understand in detail the support needs and experiences of a group of Australian children and adolescents living in families with mental illness.

METHODS

Our study is a qualitative in nature. In 2020-2021, we interviewed 25 Australian young people (M_age  = 13.60, SD = 2.26, 20 females and 5 males) living with family members affected by mental illness to understand their (the young people's) experiences, and to identify the types of support that these young people considered important or effective. We conducted reflexive thematic analyses of interview data, underpinned by interpretivist assumptions.

RESULTS

We identified seven themes within two higher-order categories reflecting our aims to understand (1) lived experiences within families affected by mental illness (i.e., increased responsibilities, missing out, and stigmatization), and (2) support experiences, needs, and preferences (i.e., respite, shared experiences with like-minded others, education, and flexibility).

CONCLUSIONS

Our findings hold substantial practical value by informing services, interventions, and conversations that better support young people living in families affected by mental illness.

Developing a Support Program for Adult Children of Parents with Mental Illness: A Delphi Study

Parental mental illness can have long-lasting impacts on a child's life. Although programs exist in supporting the needs of young children, there remains a paucity in programs that address the needs of adult children. A two-round Delphi study with adult children, academics and clinicians who have experience with parental mental illness was employed. A total of 45 and 24 participants participated in rounds one and two respectively. Open-ended questions in round one around program design and content were thematically analysed, and subsequently rated in round two. Adult children specifically identified four topics of need: (i) managing multiple roles, (ii) emotional regulation, (iii) setting relational boundaries and (iv) transition to parenthood. Current results provide the foundation for the development of modular programs that could be pilot tested with adult children who grew up with parents with mental illness.

Pilot evaluation to assess the effectiveness of youth peer community support via the Kooth online mental wellbeing website

BACKGROUND

Mental health problems among young people are of growing concern globally. UK adolescent mental health services are increasingly restricted to those with the most severe needs. Many young people turn to the internet for advice and support, but little is known about the effectiveness, and potential harms, of online support. Kooth is a widely-used, anonymised and moderated online platform offering access to professional and peer support. This pilot evaluation sought to assess changes in the wellbeing and mental health of Kooth users, and changes in their use of formal services, over one month. We explored how community aspects of the site were used, and we considered the economic implications for commissioners making Kooth available to young people.

METHODS

We surveyed young people when they first accessed Kooth and again one month later (n = 302). Respondents completed measures of mental health and wellbeing, including family relationships and pandemic-related anxiety, and reported on their use of services and, at follow-up, their perceptions of whether and how they had benefitted. We carried out qualitative interviews with ten participants, exploring perceptions of the Kooth community and its impact.

RESULTS

We found improvements across nearly all measures, including reductions in psychological distress, suicidal ideation and loneliness. Subsample analyses suggested similar benefits for those who used only the community/peer parts of Kooth as for those who engaged with Kooth's counsellors. Participants reported learning from peers' suggestions and experiences, described as different from the advice given by professionals. Helping others gave users a sense of purpose; participants learnt self-help strategies and became more confident in social interactions. Service use and opinion data suggested Kooth experiences may help users make more appropriate and effective use of formal services.

CONCLUSION

This pilot evaluation suggests that Kooth is likely to be a cost-effective way of providing preventative support to young people with concerns about their mental health, with possible benefits across a range of domains which could be investigated in a future controlled trial.

Barriers, facilitators and interventions to support help-seeking amongst young people living in families impacted by parental mental illness: A systematized review

AIM

Children living in families impacted by parental mental illness are at increased risk of adverse mental and physical health outcomes compared with children living in families unaffected by mental illness. Considered to be a hard-to reach group, it is likely that there are unique barriers for these young people in seeking help for their difficulties. This systematized review synthesizes what is currently known about help-seeking barriers, facilitators and interventions for young people affected by parental mental illness.

METHODS

Three databases were searched, yielding 2556 results and three studies were identified through other sources. Studies were screened on title and abstract review and were excluded if they were published before 2005 or if they did not include the perspectives of young people. At a second stage, full-text articles were screened based on the inclusion criteria. Eleven studies were included for data extraction and quality appraisal.

RESULTS

Qualitative and quantitative data synthesis revealed three significant barriers (i) stigma, (ii) family communication and (iii) lack of belonging and shared experience, three key facilitators (i) individual characteristics, (ii) group identification and (iii) anonymity and three primary components of therapeutic interventions (i) psychoeducation, (ii) connection with peers and (iii) accessibility.

CONCLUSIONS

It was found that stigma towards mental illness is highly salient amongst young people impacted by parental mental illness and has unique effects on their patterns of help-seeking. Help-seeking research amongst this group is still emerging, with a need for greater clarity in operationalisation of help-seeking constructs and more robust methodological designs.

How Do Children of Parents With Mental Illness Experience Stigma? A Systematic Mixed Studies Review

Stigma can have devastating health and wellbeing impacts, not just on people with mental health problems, but on people associated with the stigmatized person. This is called stigma-by-association. Children whose parents have mental health problems are a particularly vulnerable group, and stigma acts as a mechanism, contributing to the transgenerational transmission of mental disorders. The current study is a systematic mixed studies review, synthesizing knowledge about how this group of children experience stigma-by-association. Overall, 32 studies were included, after a systematic search including quantitative, qualitatative, and mixed methods studies. The methodological quality was assessed and qualitative content analysis undertaken. We grouped children's stigma experiences into four dimensions, i.e., experienced stigma, anticipated stigma, internalized stigma, and structural discrimination. Results show that stigma is an important factor in those children's lives, and needs further investigation in qualitative and quantitative research. The current study emphasizes the importance of anti-stigma interventions and campaigns.

Stigma in relation to families living with parental mental illness: An integrative review

Stigma is a pervasive social mechanism with negative ramifications for people who experience mental illness. Less is known about the stigma experiences of families where a parent has a mental illness. This review aims to identify and synthesize evidence on the concept of stigma and stigma-related experiences and outcomes reported by parents and children living with parental mental illness. An integrative review method was employed, with PRISMA (Preferred Reporting Items of Systematic Review and Meta-Analyses) guidelines to search and select literature and extract and analyse data. This approach allows for inclusion of theoretical and empirical literature and for concept definition. Fifty-eight papers, mostly from the USA, Australia, and the UK, met the inclusion criteria. Stigma was primarily conceptualized in families as a marked difference that was negatively appraised, and which could be internalized. Some articles examined how underpinning assumptions could shape the behaviour of individuals and groups and be embedded within social institutions and structures. For parents, mental illness stigma was interconnected with stigma relating to perceived violations of social and cultural norms related to parenting. Children's experience of stigma resulted in bullying, embarrassment, guilt and social isolation, and efforts to conceal their parent's mental illness. One outcome was that stigma prevented children and parents from seeking much needed supports. Public health policies and campaigns that focus exclusively on promoting open disclosure of mental illness to foster community education outcomes are unlikely to be effective without additional strategies aimed at preventing and redressing the structural impacts of stigma for all family members.

'I have cried a lot': a qualitative study on children experiencing severe parental illness

BACKGROUND

A considerable body of research has explored implications of severe parental illness on children. However, less is known about what children and adolescents with a severely ill parent experience as the most challenging.

AIMS

To describe what children with a severely ill parent experience as their most difficult challenge.

METHODS

A qualitative descriptive design with a manifest content analysis was used on data from a cross-sectional, multicenter study on children of patients in five Norwegian Health trusts. Data consisted of written textual responds from 238 children (age 8-18) to one open-ended question in a self-report questionnaire.

RESULTS

The overall theme concerning the children's most difficult challenge was named 'the drama of life unfoldment', reflecting the parental illness' impact on themselves, their relationships with others, and their life circumstances. The subthemes consisted of: Children's experiences of difficult thoughts and feelings; negatively impaired relationship with parents, friends and others; and challenging life events and obstacles in welfare.

CONCLUSIONS

The most difficult challenge experienced by the children with a severely ill parent implies life unfoldment challenges and include negative personal and relational impact, challenging life events and obstacles in welfare.

A systematic review exploring how young people use online forums for support around mental health issues

Background: Young people increasingly look towards the Internet for support. Online forums have been developed to provide mental health support, but they have received little attention in the research to date. Aims: To summarise the existing literature examining how individuals use online forums to obtain support for mental health difficulties. Methods: A systematic review of electronic databases was conducted to identify empirical literature in this area. The papers that met the inclusion criteria and satisfied quality assessment review were analysed for key themes. Results: Twenty-one papers were found. Three common themes in the papers were associated with opportunities of the technology: (1) Providing stand alone or complementary informal support, (2) Providing informational, emotional and infomotional support, and (3) Making use of the specific practical opportunities afforded by forum technology. A further three themes were associated with challenges: (1) Managing the expectations of forum users, (2) Ensuring service user safety, and (3) Navigating the technical challenges associated with forums. Conclusions: The paper highlights the potential for individuals to access dynamic and responsive support within online forums. Additionally, it reflects upon the major areas that mental health professionals need to be aware of when entering into this arena.

Development of a Moderated Online Intervention to Treat Social Anxiety in First-Episode Psychosis

Background: It is well established that social anxiety disorder (SAD) is a significant clinical problem for individuals with a psychotic disorder. Comorbid social anxiety in individuals with psychosis has been associated with poorer premorbid functioning, increased depression, and a reduced quality of life. Cognitive behavior therapy (CBT) is recommended for people with psychosis as a first-line psychological treatment; however, its focus and evaluation primarily revolves around reducing psychotic symptoms and not necessarily targeting comorbid social anxiety symptoms. We developed a novel online social cognitive behavioral intervention (entitled EMBRACE) specifically designed to treat social anxiety symptoms in first episode psychosis (FEP). Methods: The key clinical and engagement features of the intervention were established through integrating evidence-based material derived from 1) CBT-based treatment models for SAD, 2) relevant literature findings related to psychosis and its clinical correlates (e.g., shame, social rank, and its relationship with social anxiety and paranoia), 3) feedback from youth focus groups in order to inform a user-centered intervention design, and 4) a highly multidisciplinary collaborative development approach to design therapy comics. Results: A detailed description of the final version of the 12-week online social intervention to treat social anxiety in FEP is presented. Conclusion: The EMBRACE intervention was designed to provide young people with the necessary skills and confidence to overcome social anxiety within a supportive, safe online space. By design, it allows young people the opportunity to practice their newly learnt skills to connect with others and in doing so, learn to embrace their true authentic selves.

eHealth interventions for family carers of people with long term illness: A promising approach?

Family carers of people who have long term illness often experience physical and mental health morbidities, and burden. While there is good evidence to suggest that carers benefit from psychosocial interventions, these have primarily been delivered via face-to-face individual or group-formats. eHealth interventions offer a novel, accessible and self-paced approach to care delivery. Whether these are effective for carers' wellbeing has been little explored. This paper reports the first comprehensive systematic review in this area. A total of 78 studies, describing 62 discrete interventions, were identified. Interventions commonly aimed to promote carers' knowledge, self-efficacy, caregiving appraisal, and reduce global health morbidities. Interventions were offered to carers of people with a wide range of long term illness; dementia has been the most researched area, as reported in 40% of studies. Clinical and methodological heterogeneity in interventions precluded meta-analyses, and so data were analysed narratively. The most popular approach has comprised psychoeducational interventions delivered via an enriched online environment with supplementary modes of communication, such as network support with professionals and peers. Overall, carers appreciate the flexibility and self-paced nature of eHealth interventions, with high rates of satisfaction and acceptability. More studies using robust designs are needed to extend the evidence base.

Peer Communication in Online Mental Health Forums for Young People: Directional and Nondirectional Support

BACKGROUND

The Internet has the potential to help young people by reducing the stigma associated with mental health and enabling young people to access services and professionals which they may not otherwise access. Online support can empower young people, help them develop new online friendships, share personal experiences, communicate with others who understand, provide information and emotional support, and most importantly help them feel less alone and normalize their experiences in the world.

OBJECTIVE

The aim of the research was to gain an understanding of how young people use an online forum for emotional and mental health issues. Specifically, the project examined what young people discuss and how they seek support on the forum (objective 1). Furthermore, it looked at how the young service users responded to posts to gain an understanding of how young people provided each other with peer-to-peer support (objective 2).

METHODS

Kooth is an online counseling service for young people aged 11-25 years and experiencing emotional and mental health problems. It is based in the United Kingdom and provides support that is anonymous, confidential, and free at the point of delivery. Kooth provided the researchers with all the online forum posts between a 2-year period, which resulted in a dataset of 622 initial posts and 3657 initial posts with responses. Thematic analysis was employed to elicit key themes from the dataset.

RESULTS

The findings support the literature that online forums provide young people with both informational and emotional support around a wide array of topics. The findings from this large dataset also reveal that this informational or emotional support can be viewed as directive or nondirective. The nondirective approach refers to when young people provide others with support by sharing their own experiences. These posts do not include explicit advice to act in a particular way, but the sharing process is hoped to be of use to the poster. The directive approach, in contrast, involves individuals making an explicit suggestion of what they believe the poster should do.

CONCLUSIONS

This study adds to the research exploring what young people discuss within online forums and provides insights into how these communications take place. Furthermore, it highlights the challenge that organizations may encounter in mediating support that is multidimensional in nature (informational-emotional, directive-nondirective).

Accessing support and empowerment online: The experiences of individuals with diabetes

CONTEXT

The use of the internet for health information by those with long-term conditions is growing. It has been argued that this represents a form of empowerment by patients, as it enables them to control the content and flow of the information available to them. To explore this, the use of online discussion groups by those with diabetes was examined.

METHOD

Semi-structured interviews were conducted with 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely discussion boards, newsletters, and research networks related to diabetes.

RESULTS

By drawing on the advice, information, and support shared online, participants were empowered to position themselves as active participants in their own health care and to further engage with health-care professionals.

CONCLUSION

The findings indicate that forums can play a valuable role in aiding and motivating individuals in the daily management diabetes and highlight how this support is used to complement formal health services. However, more work needs to be carried out to determine to explore when and under what circumstances online support may be particularly beneficial to those with long-term conditions.

How a moderated online discussion forum facilitates support for young people with eating disorders

INTRODUCTION

Young people with eating disorders are at risk of harm to their social, emotional and physical development and life chances. Although they can be reluctant to seek help, they may access social media for information, advice or support. The relationship between social media and youth well-being is an emotive subject, but not clearly understood. This qualitative study aimed to explore how young people used a youth-orientated, moderated, online, eating disorders discussion forum, run by an eating disorders charity.

METHODS

We applied a netnographic approach involving downloading and thematically analysing over 400 messages posted August-November 2012.

RESULTS

Data analysis generated five themes: Taking on the role of mentor; the online discussion forum as a safe space; Friendship within the online forum; Flexible help; and Peer support for recovery and relapse prevention. Forum moderation may have influenced the forum culture.

DISCUSSION

Our findings are consistent with literature about youth preferences for mental health self-care support. A young person's decision to use this discussion forum can be construed as pro-active self-care. A moderated online discussion forum can make a positive contribution to support for youth with eating disorders, countering negative media perceptions of online groups.

CONCLUSION

This study adds to knowledge about how young people access support via social media. Online discussion forums can be safe and acceptable spaces for youth to access help. Further research could provide insights into the impact of forum moderation.

Children of parents with alcohol problems performing normality: A qualitative interview study about unmet needs for professional support

BACKGROUND

Children of parents with alcohol problems are at risk for serious long-term health consequences. Knowledge is limited about how to recognize those in need of support and how to offer respectful services.

METHOD

From nine interviews with adult children from families with alcohol problems, we explored childhood experiences, emphasizing issues concerning potentially unmet needs for professional support. Smart's perspective on family secrets and Goffman's dramaturgical metaphor on social order of the family focusing on the social drama and the dramaturgy enacted by the children supported our cross-case thematic analysis.

FINDINGS

The social interaction in the family was disrupted during childhood because of the parent's drinking problems. An everyday drama characterized by tension and threats, blame and manipulation was the backstage of their everyday life. Dealing with the drama, the children experienced limited parental support. Some children felt betrayed by the other parent who might trivialize the problems and excuse the drinking parent. Family activities and routines were disturbed, and uncertainty and insecurity was created. The children struggled to restore social order within the family and to act as normally as possible outside the family. It was a dilemma for the children to disclose the difficulties of the family.

CONCLUSION

Altogether, the children worked hard to perform a normally functioning family, managing a situation characterized by unmet needs for professional support. Adequate support requires recognition of the children's efforts to perform a normally functioning family.

The forum as a friend: parental mental illness and communication on open Internet forums

PURPOSE

The aim of this study was to identify how daughters or sons to parents suffering from mental illness perceive their situation. The objective was to provide new knowledge based on what they communicate on open Internet forums.

METHODS

The sample consisted of forum posts written by individuals who reported that they had mentally ill parents. Data collection comprised 301 comments from 35 forum threads on 5 different Swedish Internet forums, and predetermined inclusion criteria were used. Data were analyzed qualitatively using thematic analysis.

RESULTS

The analysis generated four themes: "Caregiver burden," "Knowledge seeking," "Support from the forum," and "Frustration and powerlessness over health care." The results showed that parents' mental illness affected the forum writers on several levels, and they often felt stigmatized. The writers often lacked knowledge of their parents' mental illness and sought out Internet forums for information and support from peers in similar situations. The psychiatric care given to the parents was a source of dissatisfaction among the forum writers, who often felt that their parents did not receive adequate care.

CONCLUSIONS

This study shows that fear of stigmatization and perceived lack of care and support caused forum writers to anonymously seek out Internet forums for information and support from others with similar experiences. The role of social support and the attractiveness of anonymity and availability typical for open Internet forums ought to be considered by health care professionals and researchers when developing new ways for providing support for children or adolescents with a mentally ill parent.