Programmes for Parents With a Mental Illness

Programmes for parents with a mental illnessjpm_1660 257..264

A . R E U P E R T 1 p h d & D . M AY B E RY 2 p h d1Senior Lecturer, Faculty of Education, and 2Associate Professor of Rural Mental Health, Department of Ruraland Indigenous Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moe, Vic.,Australia

Keywords: parental mental health,

parenting programmes

Correspondence:

A. Reupert

Faculty of Education

Monash University

PO Box 6

Clayton

Vic. 3800

Australia

E-mail: [email protected]

Accepted for publication: 24 October

2010

doi: 10.1111/j.1365-2850.2010.01660.x

Accessible summary

• Despite the benefits of parenting interventions for parents and children, there arefew documented programmes for parents who have a mental illness, with olderchildren.

• Interviewing clinicians responsible for programmes specifically developed forparents with a mental illness identifies what clinicians believe is important for theseparents and is one way of developing an evidence base.

• According to clinicians, programmes need to be responsive to parents with a mentalillness through flexibility in programme content, time and/or follow-up with casemanagement or house visits. Providing opportunities to learn from and with otherparents who have a mental illness is also important.

• Clinicians require support in articulating a sound theoretical basis for their pro-grammes and when implementing evaluation strategies.

Abstract

Parents with a mental illness experience the same parenting stressors that other parentsdo, and at the same time need to manage their mental illness. However, few pro-grammes are designed for parents who have a mental illness, with older children (asopposed to interventions for mothers with infants). This study identified the commoncomponents across six programmes developed for parents with a mental illness whohave older children. Australian clinicians, responsible for six parenting programmesfor those with a mental illness, participated in individual, semi-structured interviews,during 2008. Programme manuals and evaluation reports were also sourced. Analysesinvolved thematic analysis, inter-rater reliability and respondent validation. Data wereorganized in three main areas: (1) programme description (format, goals, length andparticipants’ inclusion criteria); (2) theoretical framework (including clinicians’ beliefsand evidence underpinning programmes); and (3) evaluation designs and methodolo-gies. It was found that clinicians facilitated education and support via a peer interven-tion model for parents with various mental illness diagnoses, responsive to the needs ofparents and in a time flexible manner. At the same time, clinicians found it difficult toarticulate the theoretical framework of their programmes and employed mostly sim-plistic evaluation strategies.

Introduction

Mental illness is a family issue, especially where a custodialparent has the mental health problem. Having a mental

illness does not preclude a parent from parenting well, butit can create a range of challenges that negatively impact onthe family, including children (Oyserman et al. 2000). Ithas been estimated that 21% to 23% of children live in

Journal of Psychiatric and Mental Health Nursing, 2011, 18, 257–264

© 2010 Blackwell Publishing 257

families with at least one parent with a mental illness(Maybery et al. 2009). Given the prevalence of such fami-lies and the difficulties some face, it is essential that appro-priate interventions are developed. In this paper, we aim toidentify core programme components of programmes spe-cifically developed for such parents, in order to consolidateinformation that can be used to guide the development offuture parenting programmes.

There are several mechanisms by which parental mentalillness increases risks for families and children involvingboth genetic and environmental factors (Hosman et al.2009). One significant risk factor for children is the parent-ing capacity of the parent. Oyserman et al. (2000) foundthat mothers with a serious mental illness have significantlyless adequate parenting skills than other mothers in thecommunity. A more recent study by some of the sameresearchers found a significant association between mater-nal mental health problems and permissive (lack of parent-ing confidence, lack of follow through) parenting andverbal hostility (Oyserman et al. 2005). Of interest is that alack of parenting confidence fully mediated the negativeeffective of poor maternal functioning on children’s aca-demic outcomes, indicating that supporting mothers intheir parenting can ameliorate at least some of the negativeeffects of maternal mental illness (Oyserman et al. 2005).

At the same time, however, it needs to be pointed outthat not all families where a parent has a mental illness areequally at risk. Maybery et al. (2009) found that of the21–23% of families affected by parental mental illness,only 1.3% have a parent with a severe and chronic mentalillness. In a sample of 405 children living with parentalmental illness, Howe et al. (2009) showed that 25% werealso exposed to parental drug and/or alcohol problems,42% were exposed to domestic violence and 16% werecurrently involved with child protection services, indicatingthat some children are exposed to multiple variables ofrisk, while others are not. Thus, families where a parent hasa mental illness are not homogenous and parenting pro-grammes and family interventions developed for this groupneed to reflect this diversity.

While there are several generic parenting programmesavailable, these are often developed as health promotionprogrammes for the whole community and fail to addressthe needs of parents with a mental illness (Craig 2004). Thedidactic method of instruction usually found in many suchprogrammes tends to be problematic for those with amental illness while the severity of a parent’s mental illnessmight make it difficult for a parent to generalize the strat-egies of the programme to home (Ackerson 2003). Issueswith motivation and stigma can also impede parents’ atten-dance to generic parenting programmes (Thomas & Kalucy2002).

There are some, albeit few, parenting programmes spe-cifically developed for parents with a mental illness. Solelytargeting maternal depression, Sanders & McFarland(2000) describe a cognitive behavioural parenting pro-gramme, which resulted in a reduction in participants’depression and child disruptive behaviour. Phelan et al.(2006) evaluated a programme for parents with variousdiagnoses, and found positive outcomes in children’sbehaviour and parenting practices. However, the dropoutrate of parent participants in this programme was high,with almost 50% of participants not completing the pro-gramme; in addition, a control group was not employed,limiting the utility of this evaluation.

There have been several studies outlining interventionsfor mothers and young infants, such as mother–baby units(Buist et al. 2004, Glangeaud-Freudenthal & Barnett 2004,Wilson et al. 2004) and programmes for parents with chil-dren under 5 years of age (Bassett et al. 2001, Steele et al.2010). As there is already some research on interventionsfor parents with very young children, and given the verydifferent parenting requirements of infants vs. older chil-dren, this study will focus on parenting programmes forparents with older children only.

The aim of this paper is to review available Australianprogrammes targeting parents who have a mental illnessand their 5- to 18-year-old children. Hinden et al. (2006)argue that analysing existing programmes and identifyingcore programme components developed for particular con-texts and clientele is one way of establishing an evidencebase. Thus, analysing existing programmes provides aninsight into what clinicians believe is important when sup-porting a particular community group. Additionally, basedon the lack of research in this area, identifying core com-ponents across programmes can identify the elements thatmight be rigorously evaluated when developing futureparenting programmes.

Aim

The aim of this study was to identify core componentsacross programmes according to:1. Programme description: format, topics, length of pro-

gramme, inclusion criteria for parent participants(including age of children) and programme goals;

2. Theoretical framework: theory (or combination of theo-ries), beliefs, assumptions and evidence underlying theprogramme;

3. Evaluation strategies and methodologies employed.

Method

In 2008, six individual, telephone interviews with clinicianswere undertaken. With written permission, 1-h telephone

A. Reupert & D. Maybery

258 © 2010 Blackwell Publishing

interviews were audiotaped, with questions based on thethree study objectives. Clinicians were also asked to email/send relevant materials about their programme, such asmanuals and evaluation reports. Ethical approval wasobtained from the university human ethics committee. Allnames of clinicians, programmes and organizations wereremoved.

Participants

Clinicians were identified via an Australian public database(http://www.copmi.net.au/jsp/copmi_programs/index.jsp),which regularly advertises programmes targeting parentswith a mental illness. Clinicians were also invited to iden-tify others who work in this area (snowballing: Rubin &Babbie 2008). Six clincians, responsible for facilitating sixdifferent programmes, agreed to participate, including twonurses, two psychologists and two social workers, whoworked in community health, welfare and outreach ser-vices. It should be noted that other professionals were alsoinvolved in the running of the programme such as psychia-trists, occupational therapists and consumers. The clini-cians interviewed in this study self-identified as the mainfacilitator of the programme.

Data analysis

Individual interview transcripts were analysed indepen-dently by the two researchers using a thematic analyticprocess. This process involved an open coding system ofanalysis, attaching labels to lines or paragraphs of dataand then describing the data at a concrete level, involving,at times, frequency counts of the various programmecomponents. Given that data were sought in three distinctareas (programme description, theoretical framework andevaluation), the content analysis process employed canbe described as a guided or directed content analysisapproach (Hickey & Kipping 1996). The two researchersthen met to reach a consensus for each of the transcripts(inter-rater reliability: Rubin & Babbie 2008). Ratherthan reach a numerical index of agreement, consensuswas reached through discussion. To add further trustwor-thiness to the data, respondent validation was sought,whereby clinicians were invited to review the researcheridentified themes and their individual transcripts, with aninvitation to change, delete and/or add anything theybelieved important (Kitto et al. 2008). After incorporatingclinicians’ feedback, across-interview analysis of the sixtranscripts was again independently conducted by the tworesearchers. Finally, one of the researchers scoped thevarious written materials about the programmes, as afurther source of data.

Findings

Programme description

Five of the six programmes presented here had been devel-oped either by the interviewee or by a former colleagueand the interviewee had ‘inherited’ the programme. Theremaining programme was an adaptation of a well-known(Australian) parenting programme. Specific modificationsto this programme included the provision of home visits toparticipants and an inclusion of parents with a mentalillness only.

Two programmes only accepted mothers. While theremaining four accepted any parent with a mental illness,participants tended to be mothers; ‘any parent is acceptedbut to date only mothers have participated’. Cliniciansreported that parents mostly came from lower socio-economic backgrounds. Specific cultural groups were nottargeted, with parents’ background being more dependenton the programme’s locality. There was no criterion for aspecific mental health diagnosis with one clinician report-ing that she accepted ‘mothers with any severe andon-going mental illness, who cares for children and lives in[the area] is welcome’. Five programmes accepted parentswith children aged up to 18 years, with one targetingparents with children 10 years of age and under.

All programmes were based on a peer support model,five programmes in a peer group setting and one offeringmentoring, where mothers were matched to other motherswith similar interests, mental illness diagnoses and geo-graphical location. Other variables included the length ofthe programme, whether individual support was also pro-vided and whether topics were predetermined (see Table 1).

Predetermined topics typically focused on parentingstrategies but at the same time acknowledged a parent’smental illness. For example, in one programme, topicsincluded ‘care of self’, as well as strategies for ‘guiding’children’s behaviour (Table 2).

While some programmes involved predetermined topics,these were still responsive to participants’ needs:

Yes, we do have pre-determined topics but if someonewants to discuss something else that is important we dotry to incorporate that as well . . . and spend less time onthat week’s topic.

All clinicians report being sensitive to how the informa-tion is conveyed and what messages are presented, forexample:

. . . we know that sometimes our parents need moretime processing information . . . or in the morning forexample, they aren’t going to be completely responsiveto their kids so parents need to be gentle with themselvesat that time of the day . . .

Programmes for parents with a mental illness


Clinicians who ran programmes within a set time frameacknowledged that many parents might not be able toattend all sessions because of illness or other circumstance.Accordingly, in these parenting programmes, topics werenot sequential and parents were able to miss one sessionand still attend the following week.

If a parent misses 1 week, we are quick to let them knowthat they can still come back. We have found that manyof these parents can’t always make a weekly committ-ment but then feel bad about coming back after missinga session. [We let them know] that it is okay to miss asession and that each week we start on somethingdifferent.

One programme ran continually, with parents comingand going, according to need:

It is up to the individual and their needs as to how longthe mother stays involved in the program. Mothers tendto come in and out of the program as their needs maychange.

Flexibility of content was also noted in two of theparenting programmes.

[the] group is consulted on what areas they would like toaddress and learn more about.

Learning with other parents was important for prag-matic reasons:

It makes more sense to work with a group of parents. . . it saves resources and time.

Another rationale for group work was the belief thatparents would learn and access support from other parents:

. . . [The] premise of the program is that parents have adegree of knowledge and empathy that we as clincians

don’t have and so can provide support to each other thatis different from what a professional might provide.Parents being together is an important way to normal-ize, to provide hope to each other.

Programmes had multiple goals, the two most importantto enhance parenting skill and confidence, and facilitatepeer support (Table 3).

Thus, while managing mental illness was a focus, it wasinterrelated to other goals.

[We aim to . . .] to place parenting centrally in the recov-ery process so their treatment and support options arenot just about the management of their illness but themanagement of its impact on their relationships, theirself-concept and role identity.

Theoretical framework

Most clinicians found it difficult to articulate the theoreti-cal framework of their programme although three men-tioned systems theory, two identified recovery theory withother theories including feminist theory, solution andstrength-based therapy. Clinicians were clearer about thebeliefs that underpinned the programme. All expressed thebelief that parents with a mental illness had the right andthe capacity to parent.

I strongly believe that these mothers have a right toparent . . . and that at times while they need support, itis the best thing for them and for their children that theyremain the primary caregivers.

Table 1Programme variables

Programme Peer format Programme length Additional individual support Predetermined topics

1 Group 6 weeks Case management Yes2 Group Unlimited None No3 Group 6 weeks Home visits Yes4 Group 6 weeks 4 home visits Yes5 Group 8 weeks Case management No6 Mentoring: one to one 1 year Clinician supports mentor relationship n/a

n/a, not available.

Table 2An example of one programme’s topics over 6 weeks

Week Topic

1 Styles of parenting, parenting skills and parenting traps2 Childhood development/developing strong family

relationships3 Communication, parental efficacy4 Guiding children’s behaviour5 Putting it all together6 Care of self, early warning signs, developing a personal

plan and final celebration

Table 3Goals of parenting programmes

Parenting programme goalsNo. ofprogrammes

Enhance parenting skill and confidence 6Provide peer support 5Self-care, improve coping strategies 4Help parents identify strengths 3Link parents with other services 3Enhance parents’ understanding about the

impact of mental illness on parenting3

Help parents help their children understandmental illness

2



In terms of an evidence base, programmes were pri-marily developed on the basis of clinicians’ prior experi-ences of working with parents. Another source was otherparenting programme evaluations although this wasqualified:

. . . [there is] not much of an evidence base specificallyavailable on parenting programs for those with a mentalillness though there is for other more general parentingprograms which is what we have drawn on.

One clinican described the evidence for the programmein this way:

There is a general evidence base [to this pro-gram] . . . the mode of delivery is efficacious, that is,peer group work where [the] group has heterogeneousqualities to it around a marginalizing and stigmatizingissue that they share.

Evaluation

The evaluation measures and designs employed by clini-cians are reported in Table 4 alongside their responses tothe question ‘What have your evaluation measures showedyou?’ Five clinicians identified participants’ satisfaction,post programme, either by questionnaire (three) or verbally(two). Five clinicians employed pre- and post-standardizedmeasures such as the Eyberg Child Behaviour Inventory(ECBI: Eyberg & Pincus 1999), the Parenting Sense ofCompetence (PSOC: Johnston & Mash 1989) and theParenting Scale (PS: Arnold et al. 1993). Clinicians werenot able to provide more information on some of thestandardized scales such as a quality of life questionnaire.Post-evaluation for all programmes occurred immediatelyafter programme completion and none of the programmestracked participants over time. All clinicians reportedoverall participant satisfaction with the programme andpositive outcomes on the various measures employed, postintervention (Table 4).

Other issues were raised by clinicians relating to pro-gramme evaluation. For example, one clinician highlightedthe sensitive nature of the evaluation process.

. . . it is vital to the program’s delivery to ensure ongoingevaluation, we all need to be creative in what and howwe deliver programmes, to ensure ongoing participationand interest to shared goals within the community . . .

Across all six programmes, there was no systematic wayof measuring dropout rates. One suggested that this wasnot necessary because

. . . parents drop in and out as they please . . . there areno set sessions and its more informal than many tradi-tional parent programs . . .

None of the evaluation designs employed control orcomparison groups.

Discussion

The development of effective parenting programmes forparents with a mental illness offers a critical opportunityfor early intervention and prevention that benefits allfamily members. According to the clinicians interviewedhere, learning from and with other parents was the primarystrategy employed, for pragmatic reasons as well as ameans of providing support and education. While referringto low-income families, Webster-Stratton (1997) describesthe social support or ‘buffering’ that parenting peer groupscan provide, a finding confirmed here. Whether this peersupport is sustained in the longer term, and the impact suchsupport has on overall well-being and actual parentingbehaviour for parents with a mental illness is as yet unclear,however, because of the mostly simplistic evaluationdesigns employed.

This study demonstrates the importance in beingresponsive to the needs of parents, by being flexible in time,programme content and/or following up with case manage-ment or house visits. Indeed, flexibility was consideredhighly significant; programmes that were time-limitedensured that topics were not sequential so that parentswere able to miss a week without feeling that they couldnot return and programmes with predetermined topicswere accommodated to the immediate needs of partici-pants. One programme allowed parents to come and go,depending on their needs and life circumstances. Overall,clinicians describe acknowledging a parent’s mental illness,within the context of parents’ child caring responsibilities,relationships and self-concept.

However, rather than incorporate broader pathways ofrisk for parents with a mental illness, such as poverty andhousing (Reupert & Maybery 2007), the programmesreported in this study focused on individual factors. Inaddition, the programmes targeted, or attracted, onlymothers, and there appears to be a service gap of pro-grammes for fathers and specific cultural groups. It shouldbe noted that only those clinicians identified via a networkpredominately orientated towards the public health sectorwere interviewed, which might have missed those workingin the non-government sector. How other countries addressthe needs of parents with a mental illness is anotherobvious avenue for future research.

Moreover, clinicians found it difficult to articulate thetheoretical framework of their programme with only apassing reference to theories such as systems and recoverytheory, without elaborating how these theories drove orinfluenced the programme. While it is not unusual forpractitioners to find it difficult to nominate the theorythat underpins their work (Dustin 2006), theory canassist programme developers to think more broadly about



intervention as well as evaluation designs. Domahidy(2003, p. 76) points out, ‘Theory is powerful because itorganizes what professionals pay attention to and howthey pay attention. It shapes beliefs that in turn shapeaction’. Given the ecological nature of parental mental

illness, a theoretical framework is required that acknowl-edges both individual (including, for example, the respec-tive needs of children and parents) and societal (suchas poverty and stigma) factors. For example, the theoreti-cal framework posed by Hosman et al. (2009), which

Table 4Evaluation measures, design and outcomes for each programme

Programme Measures used Evaluation design

Evaluation outcome/s, fromparticipants’ responses to thequestion: ‘What have yourevaluation measures showed you?’

1 Generic evaluation questionnaire used in allprogrammes across the clinician’s organization;according to the clinician this is a standardizedquestionnaire that measures ‘the numbers [ofparticipants] who have moved on to biggerand better things’. No further information onthe scale was available

Pre and post Across all measures the clinician found:‘Twelve months is not long enough forsome of the client group, it can taketwelve months or more on occasions tofeel safe in the environment beforerealising the effects of the group’

Clinician reviews individual case notes andfamily plan

Pre and post

Group discussion to gauge participantsatisfaction

Post programme, group providesfeedback and discussesexperiences with the clinician.This process also involvesmatching the groups’expectations at the beginning ofthe programme with how theyfeel at the end

2 Self-constructed satisfaction questionnaire Post ‘Women got a lot out ofprogram . . . especially the non-cliniciannature of the program’‘Being able to bring kids along is veryimportant’‘[Parents] loved outings’

3 Self-constructed, open ended questionnairethat measures confidence in looking aftermental health and well-being, relationshipswith children, knowledge of impact onchildren (Likert scaled)

Pre and post Participants demonstrate increasedknowledge about talking about mentalillness in their family

Parenting Sense of Competence (Johnston &Mash 1989)

Pre and post An increase in parent’s self-confidence

4 Self-constructed self-care questionnaire Pre and post Improvements in self-care (descriptivestatistics only)

Parenting Scale (PS: Arnold et al. 1993) Pre and post Improvements in discipline (descriptivestatistics only)

Self-constructed satisfaction questionnaire Post Participants satisfied with theprogramme

5 Quality of life questionnaire (not specified) Pre, during and post ‘Too early to say’Clinician meets with two women in thementoring relationship to obtain feedback,including satisfaction with the programme

On a quarterly basis over the 12months

Programme has been modified based onfeedback

6 Eyberg Child Behaviour Inventory (ECBI, parentform: Eyberg & Pincus 1999)

Pre and post Decreased from clinical to non-clinicalrange on ECBI

PS (Arnold et al. 1993) Pre and post ‘. . . perception of [child’s] behaviourproblem is lessened and theirknowledge and parenting skills haveimproved following the program’

Self-constructed satisfaction questionnaire(based on particular session)

End of every session Parents are satisfied with theprogramme

Self-constructed satisfaction questionnaire(based on overall programme)

Post Parents are satisfied with theprogramme



incorporates risk and protective factors related to child,parent, family and social domains, might be one modelused to guide the development of multi-componentprogrammes for families where a parent has a mentalillness. Furthermore, as evaluation and theory are inter-related, evaluation methodologies need to be aligned withthe theoretical framework underpinning any particularprogramme.

Important findings from this study were the evaluationmethods and designs employed by clinicians. Five clini-cians identified participant satisfaction either through aself-constructed satisfaction questionnaire or verbally,where clinicians responsible for facilitating the pro-gramme sought participant feedback. However, while par-ticipant satisfaction is important, we do not believe that itis sufficient as an evaluation outcome to demonstrate theefficacy or value of an intervention. There are also issueswhere clinicians responsible for a programme are obtain-ing participant feedback, especially verbally, given thatthe clinicians may not be as objective as those external tothe programme and it might well be difficult for partici-pants on these occasions to be honest about negativeaspects of the programme.

Five programmes used standardized measures, pre andimmediately post programme, including the ECBI (Eyberg& Pincus 1999), the PSOC (Johnston & Mash 1989) andthe PS (Arnold et al. 1993). The ECBI is considered areliable and valid instrument for efficient screening andtracking of disruptive behaviours in children and adoles-cents (Burns & Patterson 1990). The PS has been foundto be a valid self-report measure of parental discipline(Rhoades & O’Leary 2007) while the PSOC containsthree factors that reflect satisfaction with the parentalrole, parenting efficacy and interest in parenting (Gilmore& Cuskelly 2008). It is interesting to note that cliniciansconsidered it important to measure changes in parentingbehaviour and confidence as well as children’s behaviour.According to clinicians, when standardized questionnairessuch as these are employed as pre-/post-evaluation mea-sures, participants demonstrate improved parentingknowledge, skill and confidence as well as a reduction inchildren’s disruptive behaviour. Additionally, qualitativeevaluative feedback indicates that a considerable amountof time (over 12 months) is required to build trust amongwith these parent groups.

Comparison or control groups were not employed inany of reported programmes, making it difficult to ascer-tain how effective the programmes were under strict evi-dence criteria. It is essential that rigorous evaluationdesigns are developed so that programme factors that best

meet the needs of parents and their children are identified.While randomized controlled trials (RCTs) are often con-sidered the gold standard of programme evaluation, giventhe heterogeneous nature of this target group, RCTs maynot be feasible; indeed, it has been suggested that RCTsare less sensitive to contextual issues and unanticipatedcausal factors that can exist in community settingsthan other evaluation approaches (Patton 2008). Thesmall-scale nature of the programmes as outlinedhere and the ethical issues of randomly assigningparticipants, especially to a placebo control group(Rothman & Michels 1994), preclude the use of RCTsas an evaluation methodology for many clinicians.Moreover, many mental health professionals lack theknowledge, resources and time to implement rigorousevaluation processes such as RCTs (Reupert et al. 2009).Alternative evaluation strategies, with a particular focuson qualitative processes based in community settings,might be employed (Patton 2008) although cliniciansneed to be provided with the training, time and resourcesto do so. The programme goals identified here, particu-larly enhanced parenting skill and confidence and peersupport, provide some indication of the factors thatprogramme evaluators might target. Finally, participantdropout was not routinely identified by clinicians. Clini-cians need to identify how many participants dropout ofprogrammes, why they dropout and when, to furtherinform programme development.

In summary, while the data generated are limited toAustralia, the findings have important implications forothers when designing and delivering programmes forparents with a mental illness. Flexible and responsiveinterventions, based on a peer support framework, arefavoured by clinicians when supporting parents who havea mental illness with older children. Addressing parentingissues in conjunction with parents’ mental health needs isimportant when working with this group. At the sametime, programme evaluation that examines the long-termimpact of programmes on parenting behaviours andfamily well-being is required to provide empirical evi-dence for this clinical work.

Acknowledgments

This project was funded by the COPMI national initiative(AICAFMHA) in association with the Australian Govern-ment Department of Health and Ageing. We wouldlike to thank the clinicians and their respective organ-izations for the time and support given to us in thisproject.



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