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The Family Options psychiatric rehabilitation intervention targets families where a parent is living with or in recovery from a serious mental illness (e.g., major depression, bipolar disorder, schizophrenia and other psychotic disorders). The Family Options intervention grew out of the efforts of providers, researchers, and parents themselves to provide supports to parents and their family members at Employment Options, Inc., a community-based, recovery-oriented agency located in Marlborough, Massachusetts, USA. The aim of the intervention is to support family members in achieving their desired level of well-being and functioning, and to enhance their social supports and resources, both formal and informal. This chapter will provide (1) our rationale for intervention development; (2) an overview of the Family Options model; (3) a description of services provided; (4) a perspective on the roles of key players, including parent peers, in meeting families’ needs; (5) steps in the intervention; and (6) preliminary data regarding outcomes. We conclude with a discussion of the implications of this work for providers, administrators, and policymakers.
The rationale
Parents living with mental illnesses and their child often face multiple, complex challenges (Blewett et al., 2011). In addition, outcomes for these families are multiply determined (Nicholson and Henry, 2003). While these situations may seem daunting, in fact, this complexity suggests the relative advantage of multiple targets for intervention, as well as the potential relevance of tapping into a range of outcomes for both parents and children, over time and across domains of individual functioning and interpersonal interaction. The World Psychiatric Association Taskforce report frames recommendations for the promotion of mental health in children whose parents live with severe mental illness including the following: (1) improvements in adult psychiatric practice, (2) community support for families, and (3) enhanced collaboration with child-protection agencies (Brockington et al., 2011). These recommendations suggest the benefits of multiple modes of intervention or multimodal treatments, complicating the intervention picture even further.
Our goal was to develop and test an intervention that focused initially on parents. That is, parents are the identified or referred clients, and parents’ outcomes are prioritized. Our rationale for this focus was partially prompted by the lack of attention in adult mental health to the experiences and needs of individuals who are parents (Nicholson et al., 1996). Our impression from previous studies was that the few existing community-based interventions aimed at improving outcomes for adults who are parents as well as their children were largely untested (Hinden et al., 2006; Nicholson et al., 2007; Nicholson and Deveney, 2009). By contributing to the evidence base in adult mental health, we thought we might be able to bring adult mental health resources to bear on behalf of families. It also seemed that targeting parents, particularly in times of economic downturn and increasingly limited mental health resources, could be cost-effective in that the benefits of enhanced parent well-being and functioning would potentially be spread across multiple children. And, frankly, it seemed that greater harm could come from not attending to parents’ needs (Nicholson and Biebel, 2002).
The Family Options intervention model
The Family Options intervention was derived from our understanding that the disabilities conveyed by mental illnesses to individuals are context-related, and vary with the requirements and demands of a particular role – in this case, parenting (Nicholson and Henry, 2003). Individuals who are parents aspire to have positive family experiences and productive relationships with their children, whose ages, stages, and, consequently, needs change over time. Therefore, the Family Options intervention model, the conceptual framework upon which the intervention is based, is both ecological and developmental (Nicholson and Henry, 2003). Our intervention targets and strategies are drawn from psychiatric rehabilitation. Our overall goal is to promote recovery and resilience in all family members. This means that our focus is on the goals set by parents and families, and our intervention approach is largely behavioral, focusing on current problems and emerging solutions. We focus on enhanced skills building to improve well-being and functioning, and facilitated access to supports and resources, to link parents with networks and assets essential to achieving goals that are relevant and meaningful to them.
Our work in Family Options is guided by principles we embraced following an extensive review of the literature and of best practices in adult and children’s mental health (a “science to service” approach), and from site visits and systematic review of programs existing in the community (a “service to science” approach) (Nicholson et al., 2009). Key concepts underlying the intervention include family-centered, strengths-based, family-driven and self-determined; recovery- and resilience-focused, and trauma-informed. Key intervention processes, through which we believe change happens for parents and families, include engagement and relationship building, empowerment, availability and accessibility, and liaison and advocacy. These principles are translated into practice within the Family Options intervention on a day-to-day basis, as well as embodied in staff interactions and support, and in the larger agency environment.
We have borrowed, too, from important theories and evidence-based practices. Attachment theory underscores the importance of relationships (e.g., “My children give me strength, they give me hope, they give me the will to survive”) (Bowlby, 2005). Social cognitive theory suggests that by modifying thoughts, beliefs, and attitudes (e.g., “I am a failure as a parent”), we influence behavior change (Bandura, 1986). Motivation/behavior change theory provides a framework for considering the specific goals and relevant motivation for change for each parent (e.g., “I gotta do it for me and my kids to show them a better way”) (Miller and Rose, 2009). Strengths case management in adult mental health services (Rapp and Goscha, 2006) and the ‘wraparound’ model in children’s mental health (Walker et al., 2004) underscore the importance of strengths, supports, and resources, and the benefit of a collaborative team approach.
The notion of recovery, as developed over the past years in the mental health arena, is key to Family Options, and hope is viewed as an essential element of the recovery-oriented intervention. Success is built on strengths. Parents set goals for themselves and their families. Realistic, achievable action plans are based on “baby steps,” corrective reflection, and sensitive feedback. Goal achievement contributes to feelings of self-efficacy and the experience of empowerment (Cattaneo and Chapman, 2010). Family Options staff members attend to engagement and relationship building by being respectful, dependable, and nonjudgmental.
Services provided
Family Options includes four service components: (1) family coaching, including 24-hour availability; (2) a family team; (3) parent peer supports; and (4) clinical consultation, when necessary. We also carved out a small pool of flexible funds from the agency’s budget, to be available to families in times of emergency (e.g., fixing a flat tire on an automobile so a parent can continue to participate in Family Options activities). We consider this an optional, but desirable addition to the intervention. Detailed descriptions of the roles and responsibilities of the Family Options staff members providing these services are provided below.
Family Options staff members take a very practical, “hands-on” approach to working together with parents to set and achieve their goals. Meetings with parents and family members are held in locations convenient to them, most often in families’ homes. Goals are oftentimes quite simple and practical (e.g., find a new apartment) rather than focused on mental health-specific issues (e.g., symptoms) or needs (e.g., psychiatric medications). At 6 months following initial enrolment in Family Options, mothers’ reports of services received related to skills-building, ranked from most frequently reported to least frequently endorsed, included home and time management, conflict resolution, advocacy skills, and stress and money management. By 12 months, mothers reported receiving relatively more help with advocacy skills rather than with basic skills like time management.
With regard to supports and resources provided by Family Options, mothers’ reports at 6 months of involvement in the intervention highlighted help with transportation, recreation, and obtaining services and benefits; working with other agencies, and obtaining food and clothing were endorsed less frequently. By 12 months, relatively greater help from Family Options was targeted on obtaining services and benefits than on other categories of assistance.
Family Options is not intended as a clinical intervention per se. Our goal is to fill a perceived gap in providing coordinated, collaborative care management to parents living with mental illnesses and their families in the greatest need, to promote their participation and inclusion in family and community life. An important underlying belief is that each contact with a parent or family member has the potential to be therapeutic, from the first telephone contact with the agency, to in-person assessment and goal-setting sessions, to riding in a car together with the parent to attend an important school meeting. Family Options’ help is not limited to an hour of individual counseling or therapy in an office setting, but is targeted on meeting parents where they are “at” – both emotionally and, quite literally, physically. The 24/7 “warm line” telephone service provides round-the-clock support to parents.
Key players on the Family Options team
Parents and families
The most essential participants in Family Options are, of course, the parents and families enrolled in the intervention. Our intention is to target parents and families in the greatest need. Our referrals come from public-sector agencies, such as the Massachusetts Departments of Mental Health, and Child and Family Services (i.e., the child welfare agency), or other mental health and social services providers. Parents also refer themselves, after hearing about Family Options from friends or family members in the community. While we are committed to working with both mothers and fathers, our first cohort of parent participants, from the first 18 months of intervention implementation, comprised mothers with an average age of about 36 years (Nicholson et al., 2009). The initial group of participants was largely White (77%) with at least a high-school education or beyond (about 82%). Very few were working full-time; nearly two-thirds reported disability-related income. Approximately one-third were married or living with a partner. They averaged between two and three children, and over half lived apart from at least one minor child at some point during their lives.
Mothers had lengthy histories of disabling mental illness, beginning when they were teenagers. Most had been psychiatrically hospitalized. Over 40% reported a primary diagnosis of major depression, with others reporting PTSD (27%), bipolar disorder (18%), anxiety disorder (9%), and psychotic disorder (5%). The types and numbers of life stressors were remarkable. The majority struggled with serious money problems, had suffered abuse, had witnessed family violence as children, and had experienced the death of someone close to them. Significant numbers had been victimized sexually, stalked, robbed, or mugged. Many of the mothers reported having a seriously handicapped child (40%).
Children were spread across age groups; the majority were living at home. Two-thirds of the children required special education services, and over half had emotional or behavioral problems. Nearly half had already been assigned a mental health diagnosis. Nearly all the children had witnessed family violence and over three-quarters had been involved with child protective services.
Clearly we were successful in recruiting a cadre of mothers and children in great need. They demonstrated considerable strength and resilience from the start, simply in being able to keep their families together and children at home in situations of extreme stress and limited resources. Our goal was to partner with them to identify, set, and achieve realistic goals that were meaning and relevant to them and their family members.
Related posts:
Thinking about children of parents with mental illnesses as a form of intergenerational dialog and practice
Mothers with eating disorders and their children
Helping children understand their parent’s mental illness
E-learning professional development resources for families where a parent has a mental illness
Preventing unnecessary loss of child custody
Parental psychiatric disorder: translating The Family Model into practice change
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