NSW, Central Coast Gosford - Parent Link (Prevention Project for Parents with Mental Illness)

Parent Link was a one year pilot prevention project with dual aims. Firstly, a public health model of tertiary prevention specifically aimed to meet identified needs of parents with mental illness through providing a supportive intervention and education to families. Secondly, Parent Link was directed to provide practice development within the Adult Mental Health service through raising awareness of parents with mental illness by providing consultation and support to Adult Mental Health Teams on the Central Coast.

The Parent Link model provides a brief intervention of 4 - 6 home visits utilising a solution focused therapy combining humanistic and behavioural therapeutic methods. The model incorporates a combination of flexible and family focused activities. The Parent Link workers operated from a perspective that valued and respected the parents and thereby empowered them through the provision of education before working in partnership to develop safety plans for clients, their children and the broader family.

The first or even first two home visits from Parent Link provided a thorough assessment of families in their own home utilising their own environments to provide increased safety to families and provide a rich insight into the lived experiences of the families who were referred. The Parent Link model emphasises the need for workers to observe interactions between parents and children in their own environment because this approach enables the incorporation partners or significant others and children into the intervention and planning process.

Parent Link adopted a rigorous evaluation model to collect information in an area where there is currently a depth of information. The evaluation measures were derived from specified program objectives. The findings fall into two main areas; experiences of families who participated in the program and system level findings.

It had been anticipated in the planning of the evaluation that clinical measures would be obtained from all of the clients who engaged with Parent Link. However, in reality this was not possible due to the need to engage clients being placed as more important than the issues raised in attempting to obtain the information required to complete the clinical measures. Therefore the information reported in the evaluation is rich qualitative information gathered from referral information, the in-depth assessments of clients as recorded in the Parent Link Card and also a series of in-depth interviews with clients.

The model is based on a brief intervention utilising various other methodological frameworks including solution focused therapy. We also undertook a significant literature review on parents with mental illness to incorporate best practice into the model that was developed.

95 referrals were made to Parent Link, equating to 72 families. Most of the parents were parenting alone (51% reported being single, separated or divorced). They were most commonly aged 31-35 years (30%), caring for two children (67% of clients) and had permanent care (92%). The referral information highlights the fact that most of the parents (60%) were referred to Parent Link because of concerns about their mental illness. The data suggests that the most common diagnosis (34%) was that of depression. Interestingly, one third of the parents reported having an axis 2 diagnosis of alcohol or other drug disorder.

Other interesting information about the Parent Link clients is highlighted below:

- 51% reported having support from both family and formal (for example, statutory and government services) systems.
- Most of the parents reported that their children's behaviour and discipline was a major challenge for them.
- 79% reported that their mental illness impacted on their parenting abilities.
- Most parents reported that their children had no or minimal knowledge about their parent's mental illness.
- 34% said that they also had issues with alcohol and other drugs.
- 34% of families referred to Parent Link were also involved with the Department of Community Services.
- Parents reported that a major strength of their children was that they felt that they had high levels of emotional resilience.
- Over half of the parents (51%) said that they would like to be a better parent.
- Of interest is that 48% of parents reported that they had substantial issues with their own mothers.

Parents were also asked to identify the impact of their mental illness on their behaviour, thoughts and feelings. It was found that over half of the parents reported that their mental illness impacted to a medium or high level on their behaviour. Furthermore, 83% reported that their mental illness impacted on their thoughts (medium or high) and 75% reported feeling that it also impacted on their feelings (medium or high).

The findings of Parent Link are supported in the current literature which suggests that parents feel supported when the needs of their children are met (Cowling, 2004). In this light, it is important to consider that the parents were very aware of their role and need to be a good parent. For example, when parents were also asked to identify the impact of their mental illness on their children's behaviour thoughts and feelings 56% said that they were aware that their mental illness impacted on their child's behaviour. However, Interestingly the majority of parents did not believe that this was a negative impact.

Because Parent Link operated from the perspective that it valued, respected and listened to the lived experience of the clients who bravely committed to the program, what they told us about their lives provides a unique insight for other’s interested in replicating the model. Parent Link clients said that the intervention was helpful because they were provided with enhanced knowledge and information about mental illness and mental health issues, they learnt new parenting skills and gained an increased awareness about the needs of their children. Importantly, parent's reported the service filling a void in services. When asked what this meant, Parent said that they felt relief that someone was helping them with the issues that they had related to parenting with a mental illness, and in turn, this meant they felt increased confidence in their ability to be a parent.

In terms of systems level findings, three main issues arose, firstly there was the level of skills required to facilitate parenting interventions and support to families. Secondly, there were resource implications, for example workers may want to support families but their workloads prohibited this extension of their role. Lastly, issues arose in relation to differences in working practice, for example service models often impacted on ability and availability for information sharing.

The evaluation results highlighted the fact that Adult Mental Health staff do not feel qualified, skilled or have the resources to provide a service to clients relating to the impact of mental illness on parenting. This lead to Parent Link generally being considered to be specialist practice, not able to be adopted by adult mental health workers due to this impacting on their practice. For example, referral information from Adult Mental Health workers showed that 40% of parents had not received a home visit prior to Parent Link and in the majority of cases (51%) the children had not been sighted by the referring worker. Adult mental health staff reported that they did not feel that they were able to incorporate parenting support into their role alongside the myriad of other tasks that they were required to perform. This finding is consistent with other research findings, Kearney et al., (2000) found that many staff are expert in child protection, or mental health, or parenting support and assessment, but it is rare to find these areas of knowledge combined.

Secondly, Parent Link workers witnessed that the stress of parenting generally was a contributing factor to ongoing illness for many of the clients that they saw. This observation resulted in Parent Link workers advocating for the need for heightened awareness and acknowledgment by Adult Mental Health workers about the importance of the family in rehabilitation and maintenance role. Again the evaluation results are consistent with other studies which suggest that achieving any degree of recognition of the role as a parent by adult mental health services is difficult (Gopfert et al., 2004).

The last area of systems level findings from Parent Link relates to information sharing. This is an interesting issue, which has been reported on in research findings, for instance Mahoney (2004) suggested that adult and child services do not habitually connect and communicate. Parent Link has raised awareness about differences in service models with the experience illustrating how this separateness of services can sometimes result in disservice to families.

Messages for organisations interested in the Parent Link Model.

There were several unique aspects of the Parent Link project. Firstly, it was the only clinical pilot evaluated in New South Wales which focused specifically on the impact of mental illness on parenting. This is of significant importance because “there is no well articulated evidence base for interventions for parents with mental illnesses Nicholson, Biebel, Hinden, Henry & Stier, 2001). The information provided in the Parent Link evaluation attempts to provide some light in an area where there is little assessment of the interventions in spite of the fact that clinical experience suggests that parents with severe psychiatric disabilities can improve skills with parenting training. In fact, there have only been three studies of interventions designed for parent with mental illness which report on parenting (Brunette, Richardson, White, Bemis & Eelkema, 2004).

Whilst the Parent Link evaluation could be considered from an academic perspective to be limited by the paucity of evidence about the effectiveness of the intervention in quantitative terms, the value of the insight into the lives of parents with mental illness is believed to be of outstanding value. It cannot be overlooked that families reported feeling understood, supported, respected and empowered because they were provided options for parenting. Clients reported trusting in the Parent Link workers and said that they could talk honestly with the workers. Alongside this was the commitment to raise awareness of the unseen families of parents with mental illness and take small steps towards incorporating these people in the mental health care.

Perhaps one of the biggest issues raised by Parent Link however, that will require resource commitment in the future is to resolve the issue of who’s business parenting falls to but continuing to ensure that the drive to incorporate parenting into the practice of mental health professional is not forgotten. After all, the clients that trusted and were empowered by the intervention should be the focus of our future efforts to bridge the gap in services and undertake parenting everyone's 'business'.