The Integrated Family Approach in Mental Health Care Services: A Study of Risk Factors

BACKGROUND

Parental mental disorders in families are frequently accompanied with other problems. These include family life, the development of children, and the social and economic environment. Mental health services often focus treatments on the individual being referred, with little attention to parenting, the family, child development, and environmental factors. This is despite the fact that there is substantial evidence to suggest that the children of these parents are at increased risk of developing a mental disorder throughout the course of their lives. Young children are particularly vulnerable to environmental influences given the level of dependency in this stage of development.

OBJECTIVE

The main objective of this study was to identify whether there were a complexity of problems and risks in a clinical sample of patients and their young children (0-6) in mental health care, and, if so, whether this complexity was reflected in the integrated treatment given.

METHODS

The data were collected for 26 risk factors, based on the literature, and then subdivided into the parental, child, family, and environmental domains. The data were obtained from the electronic case files of 100 patients at an adult mental health service and the corresponding 100 electronic case files of their infants at a child mental health service.

RESULTS

The findings evidenced a notable accumulation of risk factors within families, with a mean number of 8.43 (SD 3.2) risk factors. Almost all of the families had at least four risk factors, more than half of them had between six and ten risk factors, and a quarter of them had between eleven and sixteen risk factors. Furthermore, two-thirds of the families had at least one risk factor in each of the four domains. More than half of the families received support from at least two organizations in addition to the involvement of adult and child mental health services, which is also an indication of the presence of cumulative problems.

CONCLUSION

This study of a clinical sample shows clearly that the mental disorder among most of the patients, who were all parents of young children, was only one of the problems they had to deal with. The cumulation of risk factors-especially in the family domain-increased the risk of the intergenerational transmission of mental disorders. To prevent these parents and their young children being caught up in this intergenerational cycle, a broad assessment is needed. In addition, malleable risk factors should be addressed in treatment and in close collaboration with other services.

Family Talk versus usual services in improving child and family psychosocial functioning in families with parental mental illness: a randomised controlled trial and cost analysis

Background

Parental mental illness (PMI) is common and places children at high risk of developing psychological disorders. Family Talk (FT) is a well-known, whole-family, 7-session intervention designed to reduce the risk of transgenerational psychopathology. However, very few larger-scale evaluations of FT (across only a limited number of settings) have been conducted to date while there have been no cost analyses. This study aimed to assess the effectiveness and costs of delivering FT in improving child and family psychosocial functioning in families with PMI within routine mental health settings.

Methods

A total of 83 families with PMI, with children aged 5-18 years, were randomly assigned on a 2:1 ratio to receive either the FT intervention (n=55 families) or usual services (n=28 families) across 10 adult, child and primary care mental health sites in Ireland. Parental disorders included anxiety/depression (57%), Bipolar Disorder (20%), Borderline Personality Disorder (12%), Post-Traumatic Stress Disorder (8%) and psychosis (2%). Detailed assessments with parents were conducted at baseline and 6-month follow up.

Results

FT led to significant improvements in family functioning and child behaviour at 6-month follow up when compared to usual services, with medium effect sizes indicated. Parent participants with lower mental health literacy at baseline also showed significant post-intervention improvements. Those parents with less severe mental illness at baseline, and families with more partner and economic supports, reported additional significant post-intervention improvements in child depression/anxiety and parental mental health symptoms. The cost of FT amounted to €761.50 per family, although this decreased to €415.31 when recurring costs only were included.

Conclusion

The findings from this study, which was conducted within the context of a national programme to introduce family-focused practice in Ireland, demonstrate that FT is a low-cost intervention that improved child and family psychosocial functioning across different mental health disorders within routine adult, child and primary care mental health services. The findings contribute to the growing evidence base for FT, and provide a robust basis to inform practice and policy development for families with parental mental illness both in Ireland and elsewhere.

Clinical trial registration

https://www.isrctn.com/ISRCTN13365858, identifier ISRCTN13365858.

Lived experiences of mental health nurses who care for clients who are parents: An approximation of Tronto's definition of care

WHAT IS KNOWN ON THE SUBJECT

Adult psychiatric services typically focus on the mental health needs of the client but they do not support his or her parenting role. Many authors highlight the importance of a non-judgmental approach when providing support and care to clients with mental illness who are parents. Assessments frequently focus on the negative aspects while the strengths of these families were often overlooked. There is a lack of scientific literature exploring nurses' experiences when caring for parents with mental illness and their families.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

Trust is the basis that helps clients to be open to receiving care and answering parenting-related questions. Therefore, without adequate professional-client trust, some care and interventions addressed to parents with mental illness could be poorly received by the client. Tronto's phases of care facilitated the collection of data and exploration of mental health nurses' experiences of care.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Mental health nurses should be aware of the potential needs of these families, as described in the scientific literature, so they can include them in their assessments. They also should consider the need to individualize each care since each situation of a family with parental mental illness is unique. Mental health nurses must take the person's environment into account (family, social and political aspects and different forms of stigma) since all these factors may influence how parents with mental illness receive and provide care.

ABSTRACT

Introduction Many authors highlight the importance of a non-judgmental approach when providing care to parents with mental illness. However, assessments frequently focus on the negative aspects while the strengths of such families were often overlooked. Aim To explore the lived experiences of mental health nurses who care for clients who are parents. Method We conducted a qualitative phenomenological study. The main data collection technique was in-depth interviews. Data were analysed according to Colaizzi model, subsequently, the main categories that arised were compared and related to the five phases of Tronto's care. Results The main categories identified from the analysis of the interviews were: (1) individualized care, (2) continuity of care, (3) psychoeducation and counselling, (4) trust and (5) context of the client. Discussion Trust is the basis that helps parents with mental illness to be open to receiving care and answering parenting-related questions. Without trust, some interventions could be poorly received by the client. Implications for Practice Mental health nurses should be aware of the potential needs of these families, so they can include them in their assessments. They also should consider the need to individualize each care since each situation of a family with parental mental illness is unique.

Factors that influence family-focused practice in Chinese mental health workers: A cross-sectional survey

INTRODUCTION

Family-focused practice has become an emerging paradigm in mental health services. However, little is known about family-focused practice and associated factors in Chinese mental health workers.

AIM

To examine family-focused practice and associated factors in Chinese mental health workers.

METHOD

A cross-sectional survey was conducted in a convenience sample of mental health workers (n = 515) in Beijing, China. The Family-Focused Mental Health Practice Questionnaire was used to measure family-focused practice, as well as worker, workplace and client factors that might influence family-focused practice. Multiple linear regression analysis was performed to investigate the factors associated with family-focused practice.

RESULTS

On average, the participants exhibited a moderate level of engagement in family-focused practice. The factors that most significantly influenced family-focused practice in Chinese mental health workers were skill and knowledge, worker confidence and time and workload. Moreover, psychiatrists were found to engage more in family-focused practice than psychiatric nurses, and community mental health workers were more active in family-focused practice than hospital-based ones.

DISCUSSION

This study provided important data concerning family-focused practice and associated factors in Chinese mental health workers.

IMPLICATIONS FOR PRACTICE

The varying level of Chinese mental health workers to engage in family-focused practice has advocacy, training, research and organizational implications for mental health services in China and elsewhere.

The ParentingWell Practice Approach: Adaptation of Let's Talk About Children for Parents With Mental Illness in Adult Mental Health Services in the United States

Background

Despite the importance of family and parent-focused practice, there has been a dearth of research on interventions for parents with mental illness. This paper describes the process and outcome of adapting an evidence-based intervention, Let's Talk about Children (LTC), in the context of adult mental health services in Massachusetts, United States.

Methods

Specific objectives included: (1) to specify the core components, functions, and principles of LTC essential to adapting the intervention (i.e., program theory), (2) to consider contextual factors related to the new setting; (3) to pre-test the adapted materials with diverse practitioners; and (4) to compile the program model and materials (i.e., the practice profile) for use by adult mental health service providers in Massachusetts. The Adaptation Team included individuals with expertise in psychiatric rehabilitation and clinical care, policymaking, program development and research, and parents. Activities occurred between 2015-2019 and included: (1) consulting with experts to specify the core elements and theory behind the selected intervention (i.e., with the LTC purveyor and international experts); (2) consulting with key stakeholders for input regarding the Massachusetts target population and context to inform adaptations (i.e., individual and group key informant interview sessions); (3) pretesting the initial adapted materials (i.e., training and coaching sessions with adult mental health practitioners); and (4) using feedback to refine and compile the final intervention manual (i.e., the ParentingWell Practice Profile). Participants reflected diverse, oftentimes multiple roles and perspectives, including those of parents with mental illness, adult children, and family members.

Results

ParentingWell is practitioner- and setting-agnostic, addresses parenting across the lifespan, fits into the routine workflow, and builds on practitioners' existing skills. Eight themes emerged, which were translated into four core elements (engage, explore, plan, access and advocate) consistent with Self-Determination Theory and four underlying principles (trauma-informed, strengths-based, family-focused, culturally sensitive) in keeping with the LTC model. The ParentingWell Practice Profile operationalizes each core element and addresses the underlying principles.

Conclusion

ParentingWell makes talking about parenting and family experiences a routine part of the therapeutic conversation with adults with mental illness. Future research will test the adaptation, implementation, and impact of ParentingWell.

An Evidence-Based Practice Developed in-situ: Let's Talk About Children and a Consolidation of Its Evidence Base

BACKGROUND

Traditional models of evidence-based practice assume knowledge is developed in research settings before being installed in practice settings. The role practice settings can play in enhancing effectiveness and enabling sustainability is not therefore acknowledged. Developing interventions in-situ alongside developing their evidence base, provides another pathway to evidence-based practice. One example is Let's Talk about Children (LTC), a brief family-focused intervention that promotes parent, family and child wellbeing. Let's Talk about Children has been developed and adapted to respond to the context into which it has been established, leading to different descriptions reported in its 20 year collection of evidence. Collating the diverse literature on LTC, this paper showcases an evidence-based practice developed in-situ in order to guide future innovation.

METHOD

Using an integrative review, key literature using LTC were identified through electronic databases and snowballing techniques. Constant comparison analysis synthesized the data to develop patterns and themes.

FINDINGS

From the 26 records, three forms of LTC were identified and outcomes related to parents, family and child wellbeing, implementation and sustainability were collated. Consolidated outcomes show overall agreement in effectiveness and acceptability outcomes across different settings and populations. Implementation and sustainability impacts are entwined with the context, and influenced by its development in-situ.

CONCLUSIONS

The study documents that the in-situ model is effective at developing sustainable evidence-based practice. In consolidating the evidence, the review clarified LTC's forms and outcomes, and draws attention to the importance of research on mechanisms of change.

Perspective: Implications of the COVID-19 Pandemic for Family-Focused Practice With Parents With Mental Illness and Their Families

The goal of this perspective piece is to suggest challenges to family-focused practice with parents with mental illness and their children that have emerged during the COVID-19 pandemic. We discuss implications for practice, policy, and research that will benefit from rigorous study in the future, as we sift through lessons learned. The impact of the pandemic on the mental health and well-being of people around the world has been documented. Common adaptations in service delivery have included a shift to telehealth and digital tools. The pandemic has posed challenges to practice across the EASE Framework components for family-focused practice (i.e., Engage, Assess, Support, and Educate) for both parents/families and practitioners. Governmental policy and funding responses will be critical to addressing the impact of stresses, disruptions and losses endured during the past months. Pandemic experiences and consequences have implications for research measures, methods, and outcomes, given the dramatic changes in people's lives and the contexts in which they live. The shift to research implementation in virtual environments has resulted in challenges in maintaining confidentiality, and the privacy and security of data. As we move forward, it will be important to acknowledge the remaining uncertainty about the future and accommodate the profound changes in family life, professional practice, and research implementation related to the pandemic in our efforts to demonstrate the effectiveness of positive lessons learned while developing new approaches for dealing with the negative consequences of the pandemic.

Effectiveness of family-focused home visiting for maternal mental illness: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: Maternal mental illness reduces a mothers' ability to bond with their infant and may adversely affect other family members. Family-focused practice is an approach which has the potential to support mothers with mental illnesses and reduce the risk of familial transmission of mental illness to children. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Findings suggest that current interventions are not effective in reducing depression or stress among mothers. The majority of interventions included in this review employed relatively low levels of family-focused practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While there is a growing integration of family-focused practice into home visiting guidelines, this may be based on poor evidence. There is a need for the development of rigorously tested interventions which seek to include the whole family. ABSTRACT: Introduction The evidence on effectiveness of family-focused home visiting for maternal mental illness has yet to be comprehensively synthesized. Aim The aim of this study was to assess current home visiting treatments and interventions for mothers with mental illness and their families. Method The primary and secondary outcomes of interest were depression and maternal stress, respectively, both were included in meta-analyses. We identified 13 (n = 5,540 participants) studies which met inclusion criteria. Eight studies were included in meta-analyses; five studies were reported narratively. Results Findings from the meta-analysis suggest that home visiting interventions are not effective in reducing depression (SMD -0.13, 95% CI -0.33 to 0.07, p = .21) and maternal stress (MD 0.59, 95% CI -5.19 to 6.38, p = .84). Discussion and Implications for practice Findings suggest that current interventions are not effective in reducing depression or stress among mothers. While there is a growing integration of family-focused practice into home visiting guidelines, this may be based on poor evidence.

A Sustainability Model for Family-Focused Practice in Adult Mental Health Services

BACKGROUND

Translating evidence-based practice to routine care is known to take significant time and effort. While many evidenced-based family-focused practices have been developed and piloted in the last 30 years, there is little evidence of sustained practice in Adult Mental Health Services. Moreover, many barriers have been identified at both the practitioner and organizational level, however sustainability of practice change is little understood. What is clear, is that sustained use of a new practice is dependent on more than individual practitioners' practice.

DESIGN AND METHOD

Drawing on research on sustaining Let's Talk about Children in adult mental health services and in the field of implementation science, this article proposes a model for sustaining family focused practice in adult mental health services.

SUSTAINABILITY MODEL FOR FAMILY-FOCUSED PRACTICE

An operational model developed from key elements for sustaining Let's Talk about Children identifies six action points for Adult Mental Health Services and their contexts to support the sustainability of family-focused practices. The model aims to support Services to take action in the complexity of real-world sustainability, providing action points for engaging with service users and practitioners, aligning intra-organizational activities, and the wider context.

CONCLUSION

The model for sustaining family-focused practice draws attention to the importance of sustainability in this field. It provides a practical framework for program developers, implementers, adult mental health services and policy-makers to consider both the components that support the sustainability and their interconnection. The model could be built on to develop implementation guides and measures to support its application.

Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders

Objectives: In several high-income countries, family-focused practice programs have been introduced in adult mental health care settings to identify and support children whose parents live with mental health problems. Whilst their common goal is to reduce the impact of parental mental illness on children, the mechanisms by which they improve outcomes in different systems and settings are less well known. This kind of knowledge can importantly contribute to ensuring that practice programs achieve pre-defined impacts. Methods: The aim of this study was to develop knowledge about relationships between contextual factors, mechanisms and impact that could inform a program theory for developing, implementing, and evaluating family-focused practice. Principles of a realist evaluation approach and complex system thinking were used to conceptualize the design of semi-structured in-depth interviews with individuals who led the implementation of programs. Seventeen individuals from eight countries participated in the study. Results: Interviewees provided rich accounts of the components that programs should include, contextual factors in which they operated, as well as the behavior changes in practitioners that programs needed to achieve. Together with information from the literature, we developed an initial program theory, which illustrates the interconnectedness between changes that need to co-occur in practitioners, parents, and children, many of which related to a more open communication about parental mental health problems. Stigma, risk-focused and fragmented health systems, and a lack of management commitment were the root causes explaining, for example, why conversations about parents' mental illness did not take place, or not in a way that they could help children. Enabling practitioners to focus on parents' strengths was assumed to trigger changes in knowledge, emotions and behaviors in parents that would subsequently benefit children, by reducing feelings of guilt and improving self-esteem. Conclusion: To our knowledge, this is the first research, which synthesizes knowledge about how family-focused practice programs works in a way that it can inform the design, implementation, and evaluation of programs. Stakeholder, who fund, design, implement or evaluate programs should start co-developing and using program theories like the one presented in this paper to strengthen the design and delivery of family-focused practice.

Predictors of family focused practice among health visitors: A mixed methods study

AIMS

To determine what predicts health visitors' family-focused practice with mothers who have mental illness. To explore health visitors' experiences of family-focused practice and what factors, if any, enable and/or hinder it.

DESIGN

A sequential mixed-methods design was employed.

METHODS

In Phase 1, a total of 230 health visitors, in five Health and Social Care Trusts in the UK were recruited using convenience sampling and completed the Family Focused Mental Health Practice Questionnaire. Three multiple regression models were developed to test whether workload (Model I), professional knowledge (Model II) and health visitors' professional and personal experience (Model III) predicted their family-focused practice. In Phase 2, 10 health visitors, who completed the questionnaire, participated in semi-structured interviews to describe their experiences of family-focused practice. The data collection of the two phases was conducted from September 2017 - September 2018.

RESULTS

Model III was significant. While personal experience of parenting was positively associated with family-focused practice, length registered as a health visitor and personal experience of mental illness was negatively associated. Qualitative findings suggested that increasing years of professional experience and personal experience of mental illness enabled health visitors to support mothers and their children, but not other adult family members, including partners. Limited skills and knowledge to support mothers with severe mental illness (i.e. schizophrenia) hindered family-focused practice.

CONCLUSION

This study advances understanding of how health visitors' professional and personal experiences can influence their family-focused practice and highlights the importance of organizations promoting their capacity to support mothers with severe mental illness and to include mothers' partners.

IMPACT

A clear understanding of factors affecting health visitors' capacity to engage in family-focused practice will help to inform policy, education and practice in health visiting; with potential to improve outcomes for the whole family.

Family-focused practice with EASE: A practice framework for strengthening recovery when mental health consumers are parents

This paper provides a framework for essential family-focused practices (EASE: Engage, Assess, Support, Educate) for clinicians to support parents with mental illness in the context of their family. The framework is underpinned by relational recovery as the parent/consumer's recovery is considered within the context of their relationships, including the relationship between clinician and parent/consumer. The central aim is to strengthen nurses' and other clinicians' capacity to address key psychosocial needs of parents and to strengthen relational recovery in families where parents have mental illness. The EASE framework is a theory and evidence-informed family practice approach to relational recovery within healthcare provision. The EASE practice components are defined and illustrated with practice exemplars that operationalize the framework within adult service settings. Potential applications and outcomes of using EASE are also described. The framework is intended as a practical guide for working with parents and families in inpatient and community mental health settings and may also be relevant for clinicians in a range of contexts including child welfare and primary health care.

Predictors and enablers of mental health nurses' family-focused practice

Family-focused practice improves outcomes for families where parents have a mental illness. However, there is limited understanding regarding the factors that predict and enable these practices. This study aimed to identify factors that predict and enable mental health nurses' family-focused practice. A sequential mixed methods design was used. A total of 343 mental health nurses, practicing in 12 mental health services (in acute inpatient and community settings), throughout Ireland completed the Family Focused Mental Health Practice Questionnaire, measuring family-focused behaviours and other factors that impact family-focused activities. Hierarchical multiple regression identified 14 predictors of family-focused practice. The most important predictors noted were nurses' skill and knowledge, own parenting experience, and work setting (i.e. community). Fourteen nurses, who achieved high scores on the questionnaire, subsequently participated in semistructured interviews to elaborate on enablers of family-focused practice. Participants described drawing on their parenting experiences to normalize parenting challenges, encouraging service users to disclose parenting concerns, and promoting trust. The opportunity to visit a service user's home allowed them to observe how the parent was coping and forge a close relationship with them. Nurses' personal characteristics and work setting are key factors in determining family-focused practice. This study extends current research by clearly highlighting predictors of family-focused practice and reporting how various enablers promoted family-focused practice. The capacity of nurses to support families has training, organizational and policy implications within adult mental health services in Ireland and elsewhere.

Family-Focused Practice for Families Affected by Maternal Mental Illness and Substance Misuse in Home Visiting: A Qualitative Systematic Review

Maternal mental illness is a major public health issue and can adversely affect the whole family. Increasingly, research and policy are recognizing the benefits of a family-focused approach to practice, an approach that emphasizes the family as the unit of care. This review was conducted with the aim of systematically analyzing the qualitative literature surrounding health visitors' family-focused practice with mothers who have mental illness and/or substance misuse. Through the synthesis, we developed three main findings: (a) parents' needs regarding health visitors' family-focused practice, (b) the ambiguity of mental illness in health visiting, and (c) the challenges of family-focused practice in health visiting. Above all, health visitors, families, and mothers with mental illness experience many challenges in family-focused practice, even though it is both desirable and beneficial. This calls for a deeper understanding of how family-focused practice can be effectively practiced in health visiting.

Towards relational recovery: Nurses' practices with consumers and families with dependent children in mental health inpatient units

Facilitating parent-child and family connections during parental hospitalization provides important opportunities for mental health services to support individual and family recovery. Nurses are often the primary point of contact for families in the inpatient context. They play an integral role in the care provision of consumers and families and in supporting consumers' recovery. The aim of the present qualitative study was to explore nurses' practice with families in inpatient mental health settings in the context of designated family rooms. Three themes were derived from the thematic analysis of semistructured interviews with 20 nurses from four mental health inpatient units. Nurses experienced tensions within their roles in balancing safety and risk, a lack of confidence in family-focused practices in relation to role expectations, and challenges in juggling nursing care ideals with the contemporary realities of inpatient practice. A family-centred relational recovery approach is recommended for mental health services, which is underpinned by family-focused policies and processes, and supported at an organizational, managerial, and local-unit level. At an individual level, nurses need professional development on the models of care they practice in, explicit role clarity on their practice with families, and education on evidence-based brief family interventions.

The Impact of Organizational Factors and Government Policy on Psychiatric Nurses' Family-Focused Practice With Parents Who Have Mental Illness, Their Dependent Children, and Families in Ireland

Government policy and organizational factors influence family-focused practice (FFP) in adult mental health services. However, how these aspects shape psychiatric nurses' practice with parents who have mental illness, their dependent children, and families is less well understood. Drawing on the findings of a qualitative study, this article explores the way in which Irish policy and organizational factors might influence psychiatric nurses' FFP, and whether (and how) FFP might be further promoted. A purposive sample of 14 psychiatric nurses from eight mental health services completed semi-structured interviews. The analysis was inductive and presented as thematic networks. Both groups described how policies and organizational culture enabled and/or hindered FFP, with differences between community and acute participants seen. This study indicates a need for policies and organizational supports, including child and family skills training, to promote a whole family approach in adult mental health services.

Standards of practice for the adult mental health workforce: meeting the needs of families where a parent has a mental illness

This article outlines the development of practice standards for the adult mental health workforce for addressing the needs of families where a parent has a mental illness (FaPMI). The practice standards recommended here were formulated using a modified cooperative inquiry process with a group of senior clinical leaders in adult mental health services in Australia, following consultation with the available literature and policy documents. The aim of the project was to generate, align, and operationalize family-inclusive practice standards within the core activities of the adult mental health workforce and integrate into the continuum of care and recovery for service users who are parents of dependent children. As part of a modified Delphi method, the standards were also ranked by the senior clinical leaders to determine what they believe to be essential and recommended practices for the adult mental health workforce they manage. We argue that developing practice standards that provide practical and realistic expectations of the adult mental health service workforce enable services and workers to better adapt practice to respond to FaPMI.