Supporting parents with mental illness and their children – developments in family focused practice in the United Kingdom and Ireland

It is estimated that globally between a fifth and a third of adults receiving treatment from mental health services have children, and that between 10% and 23% of children live with at least one parent with mental health problems (Maybery, Reupert, Patrick, Goodyear, & Crase, 2009; Parker et al., 2008). However, characteristics such as the gender, race and social circumstances of parents mean that the overall picture is more nuanced and that our understanding of the lived experience for families when a member has a mental health problem is still developing (Stambaugh et al., 2017). While the overwhelming majority of children living with an adult with mental health problems are loved and well cared for, that does not mean that the circumstances such children find themselves in, including those who live with adults whose use of substances is problematic, does not have an impact upon them. Additionally, in a small number of families there are more significant challenges for parents in meeting the needs of their children, including keeping children safe from abuse or neglect (Nevriana et al., 2020).

Over the past 20 years, there has been an increased focus on how to support families dealing with the mental health problems of an adult parent or adult child. This is borne from a recognition that family members need to feel supported in order to support their relative with their mental health, and that supporting an adult with their mental health has wider benefits for the entire family. Often different professionals and agencies are separately tasked with the responsibility for the care and treatment of the adult with mental health problems, and the support and protection of children. Such services and interventions have traditionally operated in tandem rather than together, leading to many individuals with lived experience of mental health problems to advocate for a more integrated approach to meeting the needs of them and their family (Reupert et al., 2018). This has led policy makers to consider how services and practice could be more family focused, while recognising the value and importance of different professionals, with their own expert knowledge and role, working in unison (Leonard, Linden, & Grant, 2018). Such family focused practice has been characterised as having a number of defining features. Foster et al. (2016) identified six core and overlapping practices within family focused practice: (1) family care planning and goal setting; (2) liaison between families and services, including family advocacy; (3) instrumental, emotional and social support; (4) assessment of family members and family functioning; (5) psychoeducation and (6) a coordinated system of care (e.g. wraparound, family collaboration, partnership) between family members and services. Marston et al. (2016) provided a similar analysis of the main components as psychoeducation; direct treatment and support for mental health and/or substance use; a focus on parenting behaviour; child risk and resilience; family communication; and family support and functioning. Family focused practice is an approach that focuses upon the family as the unit of attention, as opposed to only working with and addressing the needs of an individual service user alone, whether this is the parent with mental illness, or their child(ren) (Afzelius, Plantin, & Östman, 2018). It requires professionals to see their role as extending beyond their primary client, whether the adult or the child.

It has been encouraging to note the increased interest amongst policy makers and the providers of services to enact family focused practice, and the increasing interest within the research community for studying how family focused practice is conceptualised and practised. As a group of researchers and policy makers with expertise in adult mental health and child welfare, we have been keen to look at these developments within the context of where we are based and work, and to look for the similarities and discontinuities between the development of family focused practice in the United Kingdom and Ireland, and other regions of the world. That has been the genesis for this special issue of Advances in Mental Health – a desire to promote the sharing of learning from practice and research in the UK and Ireland with a wider international community in order to facilitate mutual learning and discussion.

The articles included in this special issue share a number of common themes, and particularly important is the need to explore, acknowledge and act upon young people’s perspectives of the immediate and enduring impact of their parent’s mental illness on them, and how professionals and services may best support and engage them to help them cope (Blake-Holmes 2019; Kearney, McCree, & Brazener, 2020; Sipler, Templeton, & Brewer, 2020). These three papers make a valuable contribution to this special edition considering the absence of research examining children’s perspectives of their experiences of living with parental mental illness in Northern Ireland and limited understanding internationally (Kallander et al., 2018; Yamamoto & Keogh, 2018). The prevalence of children who experience parental mental illness and its potential negative impact underscores the importance of acknowledging their experiences.

Another key theme is that organisations need to be aware of the factors that hinder and enable family focused practice and actively promote professionals’ capacity to support both parents and their children around issues related to parental mental illness. Hence, organisations should obtain a benchmark of family focused practice (Leonard, Linden, & Grant, 2020; Mulligan, Furlong, & McGilloway, 2020) and use this information to inform developments in policy, education/training and practice (Fitzsimons 2019; Golden 2020; McVeigh, 2020). The wider literature also highlights the importance of services developing appropriate infrastructure systems and procedures to identify and support parents who have mental illness and their children as well as training and interventions that both parents and children can engage in (Grant & Reupert, 2016; Goodyear et al., 2015; Shah-Anwar, Gumley, & Hunter, 2019).

A recurring theme in the international literature on family focused practice is that it requires an enabling and authorising policy environment, and the support of senior managers. In addition, embedding family focused practice is a process, involving the adoption of a systemic approach to how we think about the needs of families, and the organisation and operation of services. A clear message from the article by Mulligan et al. (2020) is the need to benchmark existing conceptualisations and practice in relation to family focused practice, and to use this to guide the development of new policy and practice initiatives. Their article presents data on the nature and extent of family focused practice in adult (N = 114) and child (N = 69) mental health services in Ireland. While it highlights a low level of family focused service provision, it is encouraging to note the significant openness and desire among clinicians to build capacity in family focused practice despite the challenges in so doing.

In Northern Ireland, there has been a decade of work led by the national Health and Social Care Board to embed family focused practice into all aspects of adult mental health services and children’s services. Fitzsimons (2019) reports on one aspect of this work – the introduction of local Champions – whose role is to promote family focused practice within teams and services by acting as a resource and support to colleagues, working across the mental health and children’s services interface. Twenty-six respondents to a survey provided examples of how this initiative has positively influenced their own and other colleagues’ practice, including promoting communication and collaboration between adult mental health and children’s services practitioners. However, Champions also cited a lack of dedicated time and organisational support as barriers to more fully realising the potential of this important role.

A second aspect of the strategy in Northern Ireland has been the piloting across community mental health teams of the Think Family Social Work Assessment (McVeigh, 2020). Derived from Falkov’s Family Model (2012), this seeks to support mental health social workers to have conversations with adult family members and their children about a parent’s mental health, and to identify in a structured format what supports might be helpful. The feedback from social workers and adult family members was positive about the way that children’s needs were framed, and the family were supported to discuss a child’s needs in a supported and non-stigmatising way.

The theme of looking at the barriers and enablers to professionals practising in more family focused ways is picked up by Leonard et al. (2020) who present a protocol for their study with over 400 health visitors in Northern Ireland. They propose to use the Family Focused Mental Health Practice Questionnaire to survey health visitors, and to supplement this with semi-structured interviews to explore and understand better the factors both enabling and undermining family focused practice.

A key aspect of professional development is ongoing opportunities for training. Golden (2020) presents the findings from a local training initiative in Ireland, focusing on changes in mental health professionals’ knowledge and awareness of severe and enduring mental illnesses and its impact on the family; their self-rated practice skills and attitude when working with individuals experiencing a mental illness; and their level of engagement in family focused practice. The training was well received, and participants reported improvements across all three domains assessed. However, it is noted that involving professionals from children’s services in training alongside their mental health counterparts could result in even stronger learning.

There is a growing awareness that many children are often providing care for their parent in the context of mental health problems, and yet we know so little about their needs and the immediate and enduring impacts. Blake-Holmes (2019) provides a sensitive and detailed account of what this care involves in one part of England, and children’s own accounts of how the role continues into adulthood, and the lifelong impact, such as decision making about when and if to start a family of their own, and how best to manage any future relationship between their own children and the child’s grandparent with mental illness.

Recognition is such an important first step in family focused practice – acknowledging not only the presence of children in a family with mental health problems, but the importance of seeing children as being individuals in their own right rather than an appendage to their parents. Sipler et al. (2020) present their findings on a brief intervention, Steps to Cope, which aims to build resilience within adolescents aged 11–18 years old when they live with one or both parents whose use of substances is problematic. This small scale study shows the potential for a structured approach to supporting young people at a crucial period in their own social, emotional and identity development. One of the interesting aspects of the study is the focus on young people’s positive development, rather than concentrating on the risks they face, and the need to address emotional and behavioural problems.

Developing this theme of working with children in ways which help them cope with the impact of living with parental mental illness, Kearney et al. (2020) report on a 2-year initiative in England comprising of 6, 10-week-long interlinked artist-led workshop programmes for groups of parents and their children aged under 5 years. This creative way of working shows how parents with poor mental health, who do not meet the threshold for more formal mental health services, can be supported alongside their children. The researchers found that involvement in the programme led to parents experiencing a reduction in their own depression, stress and anxiety levels. Alongside this, parents’ perceptions of their child’s socio-emotional problem scores improved during the project, highlighting the interconnectedness of parental and child well-being.

This Special Issue provides a positive and encouraging opportunity to learn more about some of the excellent and innovative developments in supporting families where a parent has mental health problems. It also reinforces how complex the issues involved may be including: considering the needs of everyone in families; their community environments and how services are delivered. Although many of the articles are focused on innovation they also highlight the ongoing, urgent need for more accessible, systemic, family focused services to be consistently and routinely available to all who need them. The potential individual, family and societal benefits of more effectively supporting families are considerable. Research has an important role in demonstrating how these benefits can be achieved and in establishing why supporting families in these circumstances should be more of a priority.