The purpose of this book is to help families by building on the conceptual frameworks, provided in the first chapter, that outline the many ways in which a parent’s mental illness can affect children, and also how parenthood itself affects illness. All authors were invited to situate their work in the context of these pre-established frameworks. We had originally hoped that the final chapter would be able to integrate information from the chapters into a new all-encompassing framework. This has proven to be impossible. A key strength of each of the three editions of this book – this edition being no exception – has been the multidisciplinary, complex, and comprehensive nature of the information presented, which cannot easily be narrowed to one guiding conceptual whole. The various chapters clearly demonstrate that there are many ways in which families where parents have a mental illness can be understood and supported. There is no single risk factor or fixed developmental course that confers either risk or resilience on children or clarifies the processes by which parental mental illness can undermine or, at times, bolster the well-being of future generations. It may be that different conceptual frameworks provide different, though equally valuable, templates to help us understand the experience of families. Similarly, one may assume that there are different paradigms in this interdisciplinary field (genetic, developmental, interpersonal, medical, and sociological), and each has its own strengths. The framework one adopts will dictate the questions being asked, the research methodology employed, and, to a large extent, the readership. This also occurs in clinical practice, as the lens, one assumes will influence how an issue is defined, the intervention goals, and the practitioner’s training requirements. Accordingly, there is still much work to be done to arrive at a definitive conceptual framework that fully explains the multidimensional processes that occur in these families.

In this concluding chapter, we highlight the distinctive features of the various conceptual frameworks presented in Chapter 1 and outline the gaps of knowledge, which have emerged from the work. The most apparent gaps are as follows:

We hope that a discussion of what is known and what is still unknown will serve to stimulate further research.

The book’s foundation is in Section 1. Sandra Bilsborrow sets the scene for the way services approach clients and their families when she presents the views of youth affected by the illness of parents. Young people want mental health professionals to “ask us what we know and what we think.” They want to be involved rather than ignored. In Chapter 3, Maybery and colleagues discuss the need to estimate the prevalence of families where a parent has a mental illness and the importance of considering the heterogeneous nature of families in regard to risk and resilience variables. Crittenden in Chapter 4 suggests that a systems approach is critical for understanding family dynamics and that all family members play a role in shaping a young person’s attachment relationships at different development stages and ages. Mihalopoulos argues in Chapter 5 that the economic cost of mental illness is a neglected research area and a priority for the future. Being able to provide a sound theoretical basis for intervention (as has been done in the attachment paradigm) alongside accurate prevalence data and a cost-benefit analysis of intervention family programs provides a compelling argument to acquire scarce resources and funds from governments and service providers.

The chapters in Section 2 consider the different ways in which families are conceptualized, depending on who is observing the family, why, and through what lens. Viewed collectively, these chapters further serve to highlight the difficulties in designing a definitive conceptual framework, as they demonstrate how different audiences (as might be seen when referring to the court system in Chapter 8) will dictate what is represented and documented. Additionally, various interpretative approaches may represent families differently – for example, by focusing on the parent’s specific diagnosis as a risk factor (see Chapter 10) or the intergenerational dialog between children and adults (Chapter 9). It would seem to us that the input of families, especially children, is central to these representations.

How different parental diagnoses affect children’s well-being is explored in Section 3. The diagnostic chapters in this third edition are able to present the results of longitudinal research, which charts the impact of parental psychopathology on children over time. Each of the chapters makes it clear that the transmission of risk to offspring is mediated by many factors within and external to the family. Children’s adverse outcomes are not merely “caused” by a parent’s mental health condition. The findings across these chapters resonate with the various conceptual models presented in Chapter 1, in that there is never a simple direct relationship between a parent’s illness and children’s outcomes; instead, various mediators clarify how and why children living in families where a parent has a mental illness may (or may not) be negatively affected. The research presented in these chapters highlights how difficult it is to tease out the comparative influences of different risk factors for children. It does demonstrate, however, that a parental mental illness does not necessarily compromise the well-being of children all the time. Similarly, as pointed out by Gladstone and colleagues in Chapter 24, certain nurturing parenting behaviors, regardless of a parent’s diagnosis, can decrease the risk of psychopathology in children, and these need to be promoted in the context of parenting interventions.

Several chapters in Section 3 (see Chapters 12, 14, 16, and especially 18, with its focus on refugee families) highlight the intergenerational impact of the trauma, a missing issue in the conceptual models presented in Chapter 1. The importance of collecting objective outcome data (e.g., children’s mental health) as well as documenting how young people understand and interpret their experiences of living with a parent with a mental illness is emphasized in Chapters 11, 15, and 18, and this also underscores the need for different methodological approaches. Chapter 18 by Philomène Uwamaliya is a welcome addition to the third edition, as one of the first pieces of work to document the impact of trauma and migration on the mental health of parents in refugee families. Further research needs to consider how a family’s cultural and linguistic background influences the expression and understanding of mental illness, the culturally dictated roles of different family members in the context of mental illness, and the culturally determined help-seeking behaviors within the family.

Within each diagnostic category there appears to be a wide range of parenting competence, just as might be seen in the general community. Seeking help, as argued by O’Shaugnessy and colleagues in Chapter 7, depends on parents’ level of insight into the effects of their disorder on themselves and their children. The symptomatology of some disorders (personality disorders or substance-abuse disorders, for example) may be associated with impaired self-awareness (see, in particular, Chapters 11, 14, 16, and 17). As discussed in the stigma chapter (Chapter 6), what “insight” means for parents can be problematic, particularly because self-stigma induces shame and guilt, which may preclude seeking help. For parents to be able to acknowledge the potential of their illness to adversely affect their children but simultaneously feel empowered and capable as parents requires a skilled, sensitive practitioner. Additionally, the severity of the parent’s illness (e.g., suicidal or psychotic) and the frequency and duration of the illness (ranging from brief reactive or endogenous) appears to be associated with the risk to children (see Chapter 10).

As can also be seen across different chapters in Section 3, the timing of the parent’s illness in relation to the child’s development is an important risk factor. Early infancy appears to be when children are vulnerable because this is when children are dependent on parents. Hence, anticipating infancy and providing support to a parent with a mental illness during preconception and pregnancy may be an opportune time to intervene. Similarly, while different children’s ages and development stages represent different vulnerabilities for both parents and children, these same periods may also provide an opportunity for different types of supports and services to approach the family.

The various intervention studies outlined in Section 4 demonstrate the value and importance of prevention and early intervention. A common message across these chapters is that, despite (or perhaps because of) the heterogeneous nature of families with mental illness, a multimodal focus is needed, one which incorporates all family members. Community leaders and other stakeholders too may need to be involved in the support of vulnerable families. The common theme arising from these chapters is that there is much that can be done, both informally, in talking to and supporting children and parents (see Chapters 19 and 22), and by formal interventions that practitioners can deliver.

Building the capacity of the workforce, organization, and community to identify and address the needs of families is the focus of Section 5. A striking finding across these chapters is that existing practices are difficult to shift, from a focus on the individual client to the family as a whole. Nonetheless, an underlying commitment to working with families is at the core of promoting change. As seen in the overview of professional development e-learning resources in Chapter 27, an effective enabler in enhancing practitioner skills is incorporating the voices and experiences of parents and children into training resources and programs. Across chapters, the importance of promoting collaborations between agencies is also recognized, not only between child and adult services, but also among housing, school, legal, and other community services. Maybery and colleagues argue in Chapter 28 that we cannot promote family-focused work without clarifying what family-focused practice entails, and appreciating that it may assume different forms depending on the practitioner and the agency. Chapter 29 further examines how parenting might be embedded in the recovery paradigm. Policies, guidelines, and organizational hierarchies have profound effects on the implementation of family-focused work, and need to be further studied.

From the outset we wanted this book to highlight the particular ways in which families with mental illness might be better supported. First and foremost is the importance of seeing mental illness within a familial context. Such a context may include extended family members, and almost always, as Cowling and colleagues argue in Chapter 23, grandparents. The identification of who should be considered part of the family context is an important goal of an initial assessment. Besides deciding who should be included, practitioners need to identify those in the family who are most at risk and what their specific needs are (see Chapters 3 and 10). One theme across all editions of this book is the possibility that children of parents with a mental illness sometimes assume a caring role, which may or may not have negative consequences for the child and accordingly needs to be considered. Open family communication is stressed in several chapters (Chapters 19, 22, and 24) to improve children’s knowledge about their parent’s illness. Facilitating a family’s access to community and agency supports and resources is another important facet of family work, covered in the conceptual frameworks of Chapter 1 and further explored in Chapter 25. Given that there are several promising interventions available for families, further work is needed to identify effective implementation processes, in order to ensure that family-focused practices are adopted in a timely manner and across helping agencies. To this end, in Chapter 32, Biebel and colleagues focus on a systems approach for implementing and promoting sustained change that cuts across community, agency, and individual practice contexts.

It is interesting to note the emerging evidence in support of interventions that specifically target parents as the catalyst for facilitating change in their families (see Chapters 21 and 22). Another focus for future research appears to be where children present to services with their problems, including behavioral disorders. In Chapter 17, Göpfert and O’Shaughnessey argue that child services need to consider the mental health of parents. Poiani-Cordella and Reupert also consider this briefly, in Chapter 15, in their discussion of mothers with eating disorders, when they highlight the opportunity for practitioners to work with parents if children present with feeding problems. Because the mental health and well-being of parents and children are intimately interrelated, working with one family member provides an opportunity for intervention and support to be directed to others within the family. How and when to sensitively “open the door” to these conversations to parents when the presenting client is the child appears to be an under-researched, though critical, topic for further exploration.

It is also perhaps useful to reflect on the title of this book, which has been carried over from previous editions, namely, Parental Psychiatric Disorder: Distressed Parents and Their Families. Parenting is challenging for everyone, not only for those who experience mental illnesses. Parents with a mental illness have to manage their sometimes debilitating symptoms as well as the everyday challenges of raising children. Nevertheless, a compelling theme across this book is that adults with mental health challenges are fully capable of raising well-adjusted children when adequately supported by formal or informal systems. Thus, in countries with developed mental health and social services, family problems might be reframed in terms of system failure – namely, inadequate services to support families, especially in times of crisis. Thus, rather than focus on distressed parents, we might instead need to target systems and social-ecological models of adaptation when identifying and addressing family needs. From this perspective, the book title might be reframed: Parental Psychiatric Disorder: Distressed Psychiatric Services.

We also need to consider a global perspective. Some Asian and most African countries offer very few mental health services, and none of these gaps are touched on in this book except for Chapter 18. An even more important question is whether our Western mental health systems are suitable for much of the rest of the world and, whether, in fact, they are optimal for the West. Alexander Leighton (as cited in Teehan, 1993) was of the opinion that current mental health services are not capable of meeting the needs of the population, as, by their design, need would never match supply. Recently, there have been concerns about the suitability of our diagnostic systems and the validity of diagnosis-based mental health services. Such concerns might provide an opportunity to help developing countries establish more appropriate ways of addressing mental health needs with approaches rooted in a public health approach (e.g., Kirmayer and Pedersen, 2014) and incorporating the needs of whole families. We also may need to rethink how we identify the needs of an individual or family (e.g., Susser and Susser, 1996a, 1996b). Throughout the world, there are differences in what constitutes a family and a community. The transitions between one stage of development and the next, the boundaries between family and nonfamily, and the concepts of good-enough parenting and child-care vary among cultural contexts – for example, a tribal culture in Waziristan (Pakistan), a mid-size industrial Chinese city, or a tribal settlement in Botswana. Service requirements will, thus, have to differ, although the need to acknowledge parental mental health will always be relevant (Chen et al., 2009; Rahman et al., 2013).

Importantly, we have, over recent years, entered a period of “austerity” that has been an almost worldwide event. We do not yet have the full picture of how this may affect mental health service development and service provision. However, first indicators seem to point to some reduction in mental healthcare provision in many countries. Leighton in 1983 described how mental health service provision tends to seesaw between community-based and centrally financed state provisions. As Solantaus and colleagues note in Chapter 22, in the West there has been a move from state-financed asylums to community-based care. While such a move was heralded as progress, it also served to cut funding and eliminate support personnel. In the UK, this often means those with a mental illness are responsible for determining their own fate, as Bell (2013) points out. Bell continues by arguing that governments no long consider welfare systems responsible for providing basic necessities for people in need but are instead a mechanism of disempowerment. Those on welfare are looked down on as “scroungers” looking to take advantage of the “nanny state” (Bell, 2013). Many disabled people identify with this ideology and see themselves as having failed, as being parasites on society and undeserving of help (Bell, 2013). Moreover, constant staff changes and organizational restructures have significant implications for the provision of mental health services and for the demoralized remaining staff. Family-focused care is particularly disadvantaged because an individualized and monetarized system of personal responsibility does not easily enable an acknowledgement of family needs. Simmel in his Philosophy of Money (2011/1900) made the point that money as a main means of exchange and for regulating affairs would over time create a subtle but consistent antirelational and antifamily bias – a point that has been expanded on by contemporary theorists (e.g., Hutchinson et al., 2002). Maybe we need to acknowledge another gap in available frameworks, in terms of the political context of services and welfare support.

All families are different and will have their own unique story to tell. Likewise, the conceptual frameworks presented in Chapter 1 each tell a somewhat different story that will be relevant to some but not all families. Given the heterogeneity of families, not only in terms of parental illness but also family form and lifestyle, culture, and language, perhaps a consensual conceptual framework will never be possible. This lack of a definitive framework should not, however, lead to the conclusion that needs are unclear, or barriers ambiguous. Since the last edition of this book, knowledge has increased (particularly as a result of longitudinal research), and to some extent and in some countries, interventions and services for families have improved. However, there is still significant work to be done, especially with respect to fostering family-focused, culture-informed, and recovery-oriented policy and practice. Providing leadership and a commitment to family work is one way of ensuring that progress is made. It is our hope that this book provides some leadership in this area, by increasing awareness about the needs of families, stimulating a commitment to seeing clients in terms of their family relationships, and offering guidance in how to work sensitively with families in crisis.