Abstract
In this chapter the authors bring together concepts around family-focused practice and recovery and translate these into particular psychiatric/mental health nursing practices when supporting such families. It illustrates how such work can be approached differently to ‘traditional’ or ‘historical’ efforts—such as they were—and focuses on families where a parent, who cares for children, has mental health challenges. The chapter points out how the recovery journey for such parents is intimately related to the relationships and interactions within their family and community. Further, the chapter also posits how focusing on the parent-child relationship not only contributes to positive outcomes in children but may also facilitate a client’s recovery. Subsequent to this, the chapter presents and considers the principles of family-focused practice, and the authors advance their theoretical framework of family-focused recovery. The chapter then examines and discusses the particular needs and associated challenges for these families, in the context of family-focused P/MH nursing. The chapter concludes by arguing that at its essence, family recovery means valuing and celebrating the family life of our clients and simultaneously conveying a sense of hope that the lives of these families will be better. It is therefore incumbent on services to provide the necessary organisational and policy initiatives that embed parenting and children as a routine part of treatment.
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1 Introduction
When practitioners work with someone with mental health challenges, typically and historically, there is and has been little consideration of their family. Or when families are considered, they are traditionally regarded as:
‘causing the mental illness in a family member, as acting to sustain the mental illness or as contributing to relapse’. (Wyder and Bland 2014, p. 180)
In this chapter, we approach families differently, with a particular focus on families where a parent, who cares for children, experiences mental health concerns. The recovery journey for such parents is intimately related to the relationships and interactions within their family and community. As argued below, it is these complex interactions within and outside of families that need to be the focus of mental health services and at least in part, psychiatric/mental health (P/MH) nursing care.
Prevalence estimates indicate that over 50% of people experiencing mental health challenges are parents (Nicholson et al. 2004) while 21–23% of children have at least one parent who experiences mental health concerns (Maybery et al. 2009). The relationship between poor parental mental health and poor outcomes in children has been well substantiated (Hosman et al. 2009) though not all children will be adversely affected. While genetics may very well play an important role in this potential impact, environmental factors are also critical. There is strong evidence that the trans-generational transmission of mental health challenges from parents to children is significantly mediated by parenting and parent-child interactions (Leinonen et al. 2003). Hence, focusing on the parent-child relationship provides an ideal opportunity for early intervention to improve outcomes for children.
Focusing on the parent-child relationship not only contributes to positive outcomes in children but may also facilitate a client’s recovery. The successes and failures associated with fulfilling a parenting role can have a profound impact on a client’s mood and how they feel about themselves and hence on their overall functioning (Maybery et al. 2015). Thus, having children can provide opportunities for supporting a client’s recovery or alternatively undermine recovery, as might occur, for example, when a parent loses custody of his or her children.
Currently there are few recovery interventions and supports developed specifically for families where a parent experiences mental health challenges. In this chapter we bring together concepts around family-focused practice and recovery and translate these into particular practices when supporting such families. We base these discussions on various projects we have conducted over the last 15 years, in partnership with parents, their families, practitioners, policymakers and other researchers in this field.
2 Family-Focused Practice
While family-focused practice (FFP) is most commonly employed in the disability and paediatric fields (Dunst et al. 2007), it is only recently being used in association with families in families where a parent experiences mental health challenges. Often used interchangeably with family sensitive, family centred and family focused, we define FFP as ‘… the involvement of families as part of the usual treatment and care of a parent with a mental illness rather than the delivery of discrete model of family intervention’ (Maybery et al. 2014, p. 608).
FFP is a collaborative approach that encompasses both the individual and his or her family (Rosenbaum et al. 1998). The principles of FFP were first developed from a review of the literature by Allen and Petre (1998) and have been expanded since (Dempsey and Keen 2008; Dunst et al. 2007). These principles are summarised as follows:
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Family is central to the lives of individuals. This means identifying the family as a unit of intervention rather than the individual with the presenting ‘problem’.
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Maximising families’ choices and abilities for informed decision-making, rather than a professional centric model of decision-making. This acknowledges that parents know their children best, know what is best for their children and have ultimate care for their children.
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Applying a strengths-based perspective, as opposed to a deficit or pathological perspective of the family. Rather than ‘blame’ the family, practitioners need to recognise that all families have strengths that can be further developed and used in problem solving.
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Recognising that all families are different and will require culturally competent services that value diversity and multiple perspectives.
At its heart, FFP provides families with opportunities to be actively involved in decisions and choices, as well as actions to achieve desired goals and outcomes (Dunst et al. 2007).
3 Recovery
For many people experiencing mental health challenges, the concept of recovery is about staying in control of their life despite experiencing a mental health problem (Leamy et al. 2011). Deegan (1996, p. 97), defines recovery as:
‘…re-establish[ing] a new and valued sense of integrity and purpose within and beyond the limits of the disability; the aspiration is to live, work and love in a community in which one makes a significant contribution…’
While the medical approach emphasises clinical recovery as a remission of mental health symptoms, the recovery model centres on personal recovery, which is aimed not so much as being symptom-free but instead:
‘living a satisfying, hopeful, and contributing life, even when there are on-going limitations caused by mental health problems’. (Mental Health Commission of Canada 2012, p. 12)
While often described as an individual journey, recovery is increasingly recognised as a relational concept, where the social environment, in particular one’s family, is critical (Reupert et al. 2015a, b). A crucial aspect of any recovery model is support for an individual’s choices including his or her choice about being a parent.
There are several links between parenting and recovery that have only recently been documented. For example, Nicholson (2014) found that children may give parents the strength and will to ‘keep going’ thereby promoting hope, a key recovery component. ‘Being a parent’ and effectively assuming the parenting role provide parents with meaning and purpose, another element of recovery (Maybery et al. 2015). Parenting may also give opportunities for meaningful interactions and activities and connections into their community (Maybery et al. 2015). Thus, identifying and supporting an individual’s parenting role can provide hope, a sense of agency, connectedness, self-determination and meaning, all cognisant with a recovery approach.
Being a member of a family can contribute to recovery in other ways. One’s parents, children, partner and others are often critical for supporting a client’s recovery journey by providing emotional as well as practical support such as undertaking household chores. Children, for example, might care for their younger siblings when their parent is very unwell, for example, or ‘having a bad day’ (Riebschleger 2004). The emotional support that families can provide should not be underestimated; Mancini et al. (2005, p. 52) found that families can provide:
‘an unwavering and steadfast belief in participants' ability to recover’while Jenkins and Carpenter-Song (2001, p. 394) reported that family members promoted recovery by:
allowing the individual to be treated as ‘just another person rather than being marked as ill and excluded’.
Finally, it is important to note that the behaviour and wellbeing of one family member may impact on others. As outlined earlier we know that children whose parents experience mental health concerns are more likely than their peers to experience a range of adverse psychosocial outcomes, and a child with his or her mental health or behavioural issues will inevitably influence and impact on the mental health and wellbeing of the parent/s. While a vicious cycle can be created between parental and child problems, it is also important to note that a virtuous cycle is possible, i.e. between parental and child recovery, with one re-enforcing the other (Compas et al. 2010). It is this intertwined nature of recovery that is the key to understanding family recovery.
4 Family Recovery
There is a paucity of literature that synthesises the concepts of FFP and recovery in relation to families where a parent where a parent experiences mental health challenges. One of the few attempts to do this comes from Nicholson (2014) though her emphasis is on mothers experiencing mental health challenges, with less attention on the recovery journey and needs of different family members. Our framework of family recovery is outlined below. The foundation of this approach is built from the core concepts of FFP (acknowledging that all families are different, a strengths-based perspective, ensuring that family members have choices) along with recovery (including connectedness, hope, identity, meaning and empowerment; Leamy et al. 2011).
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Acknowledge the family role of the client. Family recovery acknowledges, supports and celebrates the family role of clients and in particular their parenting role. This may also involve aspirational family roles in the future (i.e. wanting to be parent in the future) or the grief and loss associated with not fulfilling a role (such as not being a parent or losing custody of children). Men’s aspirations and roles in respect to fatherhood are included here (though often neglected by practitioners, Reupert and Maybery 2009).
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Families can contribute to recovery. Family recovery means recognising and valuing the critical role that family’s play in the recovery journey of clients, especially children. This means that rehabilitation plans need to incorporate and formally acknowledge families as a source of support and an essential component of a client’s recovery journey. Accordingly, families, including children, need to be routinely consulted as part of an individual’s treatment team. If we ask (or expect or assume) that families support their ill relative, it only makes sense that the family is then consulted as a part the treatment team.
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Families go through their own recovery journey. Within a recovery paradigm, we need to acknowledge the family’s own recovery journey and needs, in parallel with the consumer. This acknowledges the interdependent nature of family relationships, which change over time (e.g. when unwell, family relationships may be one sided and dependent while during the rebuilding phase, families need to ‘let go’ and move from being a carer to a support person) (Reupert et al. 2015a).
Understanding a family’s recovery journey means acknowledging different family members’ needs around identity, support, respite and psychoeducation (Wyder and Bland 2014). For family members, recovery may involve developing a life that moves beyond the caring role, learning to better manage their own distress and feeling that they are a valued part of the care team for their relative. In families where a parent experiences mental health challenges, this means that children’s needs are identified and addressed.
5 From Theory to Practice
There are multiple practices that best embrace the concepts of family recovery for families where parents experience mental health concerns.
5.1 For Parents Experiencing Mental Health Challenges
Acknowledge parenting
All clients who present for mental health treatment need to be asked about their parenting role, including reproductive goals and hopes for the future. It is also important to acknowledge the parenting role of those who do not actively care for their children, due to custody arrangements or child protection orders, as their parenting role may still be important to their overall wellbeing.
Talking about parenting
Family recovery means that ongoing conversations about parenting and caring for children are embedded into treatment discussions and plans.
Initiating discussions about parenting and children within the context of a mental health treatment is not easy however. The stigma associated with mental health issues means that parents and practitioners might be reluctant to discuss mental health issues in the context of family life. Additionally, in some countries, mental health concerns is a legally accepted reason for custody loss (see Kaplan et al. 2009), regardless of the client’s parenting ability. Other research has found that many mental health practitioners, including P/MH nurses, do not have the necessary skills and knowledge to work with clients on parenting or their children (Maybery and Reupert 2009). Appropriate training along with supervision and time is necessary for practitioners to practice family recovery (see Reupert et al. 2015b for more information on particular training approaches and models).
Hence it is important to address the reluctance that some parents might have in talking about their children or their parenting. If discussing parenting and children is not a routine part of treatment, such discussions can be surprising or even alarming, particularly if parents are concerned about the involvement of child protection services (Solantaus et al. 2015). Nonetheless, many parents want to talk about their children and are often relieved when given the opportunity to do so (Solantaus et al. 2015). The following is an example script of how a practitioner might ‘open the door’ to talking about parenting and children in a sensitive manner (adapted from Solantaus et al. 2015).
‘Many parents who experience mental health issues have questions or concerns about their children. They often worry about things they have noticed or they may have questions about how best to support them. They may also worry about how their illness impacts on their parenting role. Something things go along smoothly, but at other times, thing can be more challenging – and these things can be hard to discuss in familiesFootnote 1*. Many parents would like to know if there is something they can do for their children… If you are concerned or worried about any of these issues, would you like to discuss them? I might be able to help you in working out what you can do for your childrenFootnote 2**’.
5.2 Children Whose Parent Has a History of Mental Health Problems
Children living in families where parents experience mental health challenges need the same love and security that all children need. Nonetheless, family recovery means that their particular needs are considered and addressed at the same time as their parents.
Giving children a voice
It has been said that children whose parents experience mental health challenges are ‘invisible’ as services predominately attend to their parent (Trondsen 2012) unless there are serious issues around neglect or abuse. Practitioners need to give these children a voice and opportunities to ask questions, consult about their needs and seek their views as to what they think should happen in their family. Their input is especially important when planning for crisis times, for example, deciding where a child might stay when a parent is hospitalised (Reupert et al. 2008).
Opportunities to talk about their parent’s illness
A common need, articulated by youth themselves, is the opportunity to have conversations about their parents’ illness. When child centred and in an age appropriate manner, such conversations may address children’s fears about what is happening in the family (Cooklin 2013). Interestingly, many youth want to hear about their parent’s illness from the parent themselves (Reupert et al. 2012), and practitioners might work with parents around how they might do this.
Caring role acknowledged
Some children whose parent experiences mental health challenges assume a caring role of their siblings and/or parent (Reupert and Maybery 2007). While caregiving has been associated with limiting young people’s friendships and schooling, there is growing recognition that the experience of caring can be positive in developing closer family ties and independence (Aldridge and Becker 2003). It is important that this caring role is acknowledged and that children are consulted accordingly. Respite from these caring responsibilities may also be warranted.
5.3 The Family as a Whole
A strengths-based approach
Rather than focusing on limitations or deficits, a strengths-based approach means practitioners highlight the potentials, strengths, interests, abilities and capacities of parents and their children (Grant and Cadell 2009). This approach is not about denying any problems the parent or child may be experiencing but instead working collaboratively with the parent on mutually agreed goals and drawing on the resources of the family and the community. It is this harnessing a family’s resilience that provides the basis for addressing the challenges that they may be facing. Accordingly, parents need to be encouraged to identify strengths for themselves and their children, which in turn may make them feel more positive in their relationships (Nicholson 2014).
Collaborative goal setting typically involves a case management approach in which meetings are held with each family member and the family as a whole to identify short- and long-term goals (Maybery et al. 2012). The practitioner might prompt some key domains around family life and child development and together work out what needs to happen, by when and with whom. For example, goals for children might include wanting to learn more about their parent’s illness or having a sleep over at a friend’s house. For parents, example goals might involve improving the way they deal with anger or putting aside money for family outings. During this process, the roles and responsibilities of external agencies and informal family networks are negotiated by family members and/or the practitioner. The role of the practitioner is to support each family member to achieve their particular goals over time, drawing on various community and family supports.
Conclusion
Family recovery synthesises two seminal constructs, FFP and recovery, with subsequent practice and organisational implications for how we might work with clients who are parents and their children. At its essence, family recovery means valuing and celebrating the family life of our clients and simultaneously conveying a sense of hope that the lives of these families will be better. It is therefore incumbent on services to provide the necessary organisational and policy initiatives that embed parenting and children as a routine part of treatment.
Notes
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*These statements send a message to the client that it is normal to have concerns about their children and that other parents have also been in this situation. The practitioner joins with the parent in their possible concerns and gives the parent permission to talk about any issues they might have. This is different from opening the discussion with, ‘How are your children?’ which might make the parent feel uncomfortable and defensive.
- 2.
**It is important to let parents know that they can do things for their children rather having to rely on services, a stance that can be a genuine source of empowerment for the parent.
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Maybery, D., Reupert, A. (2018). A Family-Focused, Recovery Approach When Working with Families When a Parent Has a History of Mental Health Problems: From Theory to Practice. In: Santos, J., Cutcliffe, J. (eds) European Psychiatric/Mental Health Nursing in the 21st Century. Principles of Specialty Nursing. Springer, Cham. https://doi.org/10.1007/978-3-319-31772-4_22
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