There are multiple barriers to the adult mental health workforce becoming family focused.
Adult mental health services need to identify consumers who are parents and respond to children, parenting and family needs.
The introduction of family and child friendly policies and procedures in adult mental health settings is a necessary step in systems change in this area.
The skills and knowledge of the adult mental health workforce about children and parenting would be enhanced with education and professional development.
It is important to encourage consumers to include family members and dependent children in their treatment.
It is thought that up to 23% of children live in families with a parental mental illness.1 Evidence is emerging, that where parental mental illness is severe, it is associated with multiple mental and developmental risks in offspring (e.g. higher infant mortality risk and insecure infant attachment).2,3 As 20.4% of severely ill consumers of adult mental health services are parents, these services are an important point of intervention for children.1 While child-focused family work represents a new preventive approach,mental health services traditionally view the ill parent as the only one in need of help.4,5 Recent evidence has shown that family focused interventions are effective, with sustained improvement, over time, in parent illness-related behaviours and reduced internalising symptoms in children.6
Workplace policy and management
Structural aspects of the health care system and models of professional practice limit family participation within adult psychiatric services.7 There is a lack of policy and consistent guidelines to identify the parenting status of consumers when they access psychiatric services. While Byrne et al,found that two thirds of the 77 mental health workers surveyed recorded the parenting status of their clients, this is not routine practice.8,9 Other management issues include the inadequate resource allocation for family focused practice, the provision of time, high workloads,moneyand role constraints.8,10,11,12 Workplace culture can also be a problem, with the suggestion that some workers are embedded within a culture that is orientated more towards the illness and the individual.10 Additionally, some managers do not support family focused interventions because of their outdated beliefs that the family is a major cause of the problem.13 Another impediment to family focused practice is the lack of liaison and collaboration between services due to lack of structures, policies, procedures and resources.14
Worker attitude, knowledge and skill
A family oriented approach requires sufficiently well trained staff.12 Many adult mental health workers report that they do want to work with family members but report clear skill and knowledge limitations including working:
on clients’ parenting issues
with the whole family.15
For example, some workers report difficulties engaging and interacting with children.10 Dean and Macmillan argue that some workers do ‘not know how to assess how the adult consumer was doing as a parent beyond looking for obvious indicators of abuse and neglect.’16 Various workers report a reluctance to work on child related issues because they believe it will disrupt the therapeutic alliance with their parent-client and/or may raise client confidentiality issues.15,17 It has also been suggested that profession ‘centric’ rather than ‘client-centred’ training stifles improvement and innovation.11
Parent, child and family engagement
A final series of obstacles consist of engagement issues. The most pervasive factor affecting parents’ access to and participation in mental health services is the stigma accompanying mental illness.18 Following parent engagement in services, some parents are reluctant and/or unwilling to involve their children and other family members in treatment (or psycho-education) due to their own needs or their fears regarding child protection.15,19 In addition, some parents don’t acknowledge the possible adverse effects of their illness on their children.19 Mental health workers have also suggested that some family members, including children, are not willing to be involved in the treatment of their mentally ill relative and/or are unable to attend because of transport and distance difficulties or because they are in foster care.15 However, others have suggested that carers want to be listened to, supported and involved in the planning of their relative’s care.20
Workforce barriers are typically identified from workers’ perspectives, rather than the views of different family members. This is particularly problematic when workers identify issues relating to parent, child and family engagement. Furthermore, in comparison to research that focuses on workforce barriers, there are fewer studies that identify the strategies that enhance workforce change.
Ongoing supervision and opportunities for further education are essential for workers to meet the needs of all family members.21 Overall, there is a clear need for family sensitive policies and procedures, managerial and organisational support and well targeted and sustained workforce development.
Maybery, D., Reupert, A., Goodyear, M., Patrick, K., & Crase, L. Prevalence of children whose parents have a mental illness. Psychiatr Bull R Coll Psychiatr, 2009; 33.
Webb, R., Abel, K., Pickles, A., & Appleby, L. Mortality in offspring of parents with psychotic disorders: A critical review and meta-analysis. Abbreviation: Am J Psychiatry, 2005; 162, 1045-1056.
Frankel, K.A., & Harmon, R.J. Depressed mothers: They don’t always look as bad as they feel. J Am Acad Child Adolesc Psychiatry, 1996; 35, 289-298.
Solantaus T. & Toikka S. The effective family programme: Preventative services for the children of mentally ill parents in Finland. J Ment Health Promot, 2006; 8, 37-44.
Singleton L. Parental mental illness: the effects on children and their needs. Br J Nurs, 2007; 16(14),847-50.
Beardslee W.R., Wright, E.J., Gladstone, T.R.G., & Forbes P. Long-term effects from a randomized trial of two public health preventive interventions for parental depression. J Fam Psychol, 2008; 21, 703-713.
Byrne, L., Hearle, J., Plant, K., Barkla, J., Jenner, L., & McGrath, J. Working with parents with a serious mental illness: what do service providers think? Aust Soc Work, 2000; 53, 21-26.
Maybery, D. & Reupert, A. (in press). Parental mental illness: A review of barriers and issues for working with families and children. J Psychiatr Ment Health Nurs.
Korhonen, T., Vehviläinen-Julkunen, K., & Pietilä, A. Implementing child-focused family nursing into routine adult psychiatric practice: Hindering factors evaluated by nurses. J Clin Nurs, 2008; 17, 499-508.
Conway, J., McMillan, M., & Becker, J. Implementing workforce development in health care: A conceptual framework to guide and evaluate health service reform. Hum Resour Dev Int, 2006; 9, 129-139.
Slack, K., & Webber, M. Do we care? Adult mental health professionals’ attitudes towards supporting service users’ children. Child Fam Soc Work, 2008; 13, 72-79.
Smith, G., & Velleman, R. Maintaining a family work for psychosis service by recognizing and addressing the barriers to implementation. J Ment Health, 2002; 11, 471-479.
Darlington, Y., Feeney, J. A., & Rixon, K. Interagency collaboration between child protection and mental health services: Practices, attitudes and barriers. Child Abuse Negl, 2005; 29, 1085-1098.
Maybery, D., & Reupert, A. Workforce capacity to respond to children whose parents have a mental illness. Aust N Z J Psychiatry, 2006; 40, 657-664.
Dean, C., & Macmillan, C. Serving the children of parents with a mental illness: barriers, break-throughs and benefits. Paper presented at the Building Bridges: Promoting mental health for families and communities; 2001.
Wynaden, D., & Orb, A. Impact of patient confidentiality on carers of people who have a mental disorder. Int J Ment Health Nurs, 2005; 14, 166-171.
Kai, J & Crosland, A. Perspectives of people with enduring mental ill health from a community-based qualitative study. Br J Gen Pract, 2001; 51, 730-737.
Stallard, P., Norman, P., Huline-Dickens, S., Salter, E., & Cribb, J. The effects of parental mental illness upon children: A descriptive study of the views of parents and children. Clin Child Psychol Psychiatry, 2004; 9, 39-52.
Stanbridge, R., & Burbach, F. Developing family-inclusive mainstream mental health services. J Fam Ther, 2007; 29, 21-43.
Jones, A. & Scannell, T. Research and organizational issues for the implementation of family work in community psychiatric services. J Adv Nurs, 2002; 38 (2) 171-179.