Initiating communication about parental mental illness in families: An issue of confidence and security

Beardslee’s family intervention

Settings and participants

Participants were recruited by professionals who conducted FIs in Sweden during 2007. The interviewees in this study had participated in FIs conducted by a total of 26 professionals from general psychiatric services who had participated in the first FI training groups in Sweden. All but one of the FIs were carried out by pairs of professionals.

Twenty four of 70 families who had responded to the questionnaire in a previous study (Pihkala et al., 2010) were requested to participate in the interviews and at least one member from each of 18 families accepted to take part. The selection was strategic in order to gain variation in the IP-parents’ (patient) diagnosis, in the clinical setting and in the professionals. Reasons for declining to participate in the study were not requested. The families were from nine clinics, ranging from northern to southern Sweden.

Members from 18 families were interviewed and a total of 39 interviews were carried out. Fourteen of these family members were children from nine families. Six complete families were interviewed. In seven families, only one member accepted to be interviewed; in six cases this was the IP-parent, in one case the NIP-parent (non-patient). These parents stated that the other family members had not wanted to participate. The biological parents were living together in 10 of these 18 families. In one case the interviewed NIP-parent was a step-parent. Two families had an ethnic background other than Nordic. One of the FIs was conducted with an interpreter by phone.

In 11 families the IP-parents’ clinical diagnosis was depression. Two parents were diagnosed with personality disorder, one with bipolar syndrome, one with both generalized anxiety disorder (GAD) and attention deficit hyperactivity disorder (ADHD), one with psychosis NUD and one with post-traumatic stress disorder (PTSD). In the family where only the NIP-parent was interviewed, the IP-parent’s diagnosis was bipolar syndrome. All but one of the IP-parents had continuous contact with a psychiatric clinic and were on medication at the time for the interview. Half of them had been hospitalized at least once (Table 1).

OPEN IN VIEWER

Table 1.

The parents

	N	Median age (range)	IP	NIP	IP-parent on sick leave
Female	14	40 (31–50)	11	3	11
Male	11	40 (35–46)	6	5	3
Total	25	40 (31–50)	17	8	14

The 14 children were interviewed individually; there was an equal number of boys and girls and the age range was 6–17 (median 12 years). Three pairs of siblings and three siblings in one family were interviewed. None of the children had a psychiatric diagnosis. (The children’s experiences will be presented in a future paper.)

This study was approved by the local ethics committee of Umeå University (Dnr 07-002M).

Data collection and analysis

Data was collected via qualitative interviews (Kvale, 1996) carried out by the first and third authors during 2007–2008. Both are engaged in the implementation of FI in Sweden but did not conduct the FIs for the interviewees.

The families decided on where the interview was to take place; 10 families chose to be interviewed at home, five at a clinic, one at a primary healthcare centre and two interviews were conducted by phone due to long distance or lack of time for the parent. Two parents from one family were interviewed through an interpreter.

The interviews were as open ended as possible. The parents were initially invited to talk about the FI, with the interviewer reminding them about the different phases if necessary. Topics covered included what the parent thought about the set-up of the FI, the child interviews, communication within the family, difficulties faced, what the other family members thought, and the role of the professionals. The interviews lasted 40–50 minutes. They were recorded and then transcribed by an assistant; the transcripts were validated against the recordings.

The interviews, transcriptions and analysis were carried out on a parallel basis. Grounded theory (GT) was chosen as it is an inductive method, appropriate for an unprejudiced examination of the parents’ experiences. First, the researchers coded the transcripts line by line independently, then compared the codes. A number of categories and subcategories were established, which were used to establish one central category. The criteria for the central category were that there were indicators pointing towards it in almost all cases and that all other categories could be related to it (Strauss and Corbin, 1998) (Table 2).

OPEN IN VIEWER

Table 2.

The analysis process from text to categories

Quotation from the interview text	Subcategory	Category	Central category
“They were good persons, they had been doing this for a while.”	Competence	The Professionals
“I didn’t feel controlled, it was relaxing.”	Attitude
“It was not a bad thing to have talked with them (the professionals) first (before the child interview).”	Structure	The FI as a method
“It was good, that they could come home and talk with our son, otherwise it would not have come off.”	Flexibility		Confidence and security
“I had thought about it for a long time, but had not had the courage to ask the girls what they thought about it. Now I could do it.”	Listening to the children’s experiences	Getting help in starting to talk about mental illness
“I think I told them (the professionals) what I wanted to say to the children and they gave me some ideas for key words.”	Finding the words
“It was necessary that the professionals were there, otherwise I would not have had the strength to do it, I knew what to say, but I didn’t have the ability to say it.”	Getting support from the professionals

Using constant comparative analysis, codes found in the interviews with NIP-parents were compared to those in the entire material, as well as codes found in interviews of parents with different parental diagnoses in the family. The results are presented only when the codes varied considerably.

Parents’ perception of the professionals

The following are typical statements from the parents:

I think there is such a caring spirit in this concept. (family 15, IP-mother, psychosis)

They were so professional, really skilled at their job. (family 3, NIP-mother)

The professionals’ attitude towards the parents was perceived as positive. The parents said that it was easy to talk with the professionals, who were just ordinary people, like ‘fellow human beings’. They were straightforward and did not complicate matters, and treated the parents in a fair, non-controlling way. The professionals were also perceived as supportive, empathic and caring and the atmosphere in the sessions was informal. Many parents described that, after the two first sessions, they already felt a confidence in the professionals and it made them feel secure in the FI process.

Professionalism and the ability to talk with the children and to express matters in an appropriate way were valuable to the parents because they were confused about how they themselves should talk to them about the illness. Many parents pointed out how pleased, relieved or astonished they had been that their children had talked openly with the professionals. They stated that the children also gained confidence in the professionals. The parents had not had high expectations before the FI, but their views soon turned positive. Competence was used in the description of the professionals, who were perceived as experienced and skilled by the parents.

FI as a method from the parents’ perspective

The structure of the FI was described as well-thought-out, solid, educational and ‘ordinary’. The parents said that they received information about what was going to happen next and their sense of control increased.

It was so solid in some way…you had their back-up if problems were to occur with the children. If you start something like this on your own, you don’t know where it can end.’ (family 2, NIP-mother)

It was good that we did not dig in so deeply, it’s more like a normal conversation about these matters, what it means having the illness. (family 15, IP-mother, psychosis)

Being able to meet the professionals twice before the children were interviewed was especially appreciated by the parents. They were able to talk about their experiences of the mental illness in the family and about their concerns for their children. The parents were prepared and felt confident before moving to the next step in the process, because they had got to know the professionals.

I was able to get a sense of security in myself. (family 2, IP-father, depression)

The two sessions also gave the parents an opportunity to listen to each other. For some IP-mothers it was an important experience that their partner was open and could share his worries and thoughts for the first time. The parents described that they gained greater understanding and came closer to each other in their views about their children.

The possibility to follow-up and to contact the professionals if concerns about the children arose gave the parents a sense of security. They now had someone who already knew both the children’s and the family’s situation so they would not have to start again from the beginning with new people.

In summary, the structure of the FI was experienced positively, as solid, logical and predictable, providing a sense of security and control for the parents. It also gave them an opportunity to talk about their situation.

The flexibility of the FI was spoken about by the parents. It included the option of home visits, which were seen in many cases to be a prerequisite for the children’s participation.

I think it was very good to have those sessions at home, it was more relaxed. Because this is so emotional, it feels safe being at home. In the psychiatric clinic you feel so small.’ (family 6, IP-mother, depression)

In some cases the parents preferred to have the sessions at a clinic, in order to prevent conflicts during the family session and in order to have more concrete framework and rules for the session. This seemed to be the case in the families who experienced many conflicts.

It was good not to be at home, nobody could get angry and just leave. (family 4, NIP-father)

It was also possible to have extra sessions when needed and parents could influence the pace of the FI, which thus contributed to the sense of control.

We had an extra session because we had so much to talk about, that was good. (family 15, NIP-father)

On the whole, the FI gave the parents the opportunity, the time, the place and a framework to begin to talk about such a difficult issue with their children. The parents did not believe that they would have been able to talk in this way within the family by themselves; there was a need for someone who could be in charge of the discussion.

It may not have become so big, so serious if they [professionals] had not been with us.’ (family 5, IP-mother, depression)

Getting help in starting to talk about mental illness

It was a bit hard when they talked about my son…the judgement in black and white…how you have been as a parent, but it was good to get to know it…’ (family 10, IP-father, depression)

Listening to the children’s experiences was a challenge for many parents. All the parents had been concerned about their children’s well-being before the FI, which had been the main reason for their participation. Feelings of guilt were connected with the issue of the children’s well-being for all the IP-parents. Feelings of shame were also associated with the children’s experiences. Thus, the moment when the children were about to be interviewed or when the parents got feedback from these interviews could be charged with anxiety. The confidence they had in the professionals made it easier for parents to let their children be interviewed and to receive the feedback.

It was real tough to take it, what should they [the professionals] think about me…but I trusted them…I thought they have probably seen worse things.’ (family 14, IP-mother, depression)

I felt foolish, it was not easy, but it was good. (family 17, IP-father, ADHD)

The issues of guilt and shame were not present in the interviews with the NIP-parents.

For several parents it was crucial to get concrete help with finding the words and formulations that were appropriate for the children: on the right level, not too complicated, short enough, not too emotional or abstract. This help could be very concrete, the professionals suggesting suitable words for the parent after the parent had explained what he/she wanted to say. Some parents wrote down what they wanted to say in the family session.

I got the opportunity to learn how to explain to my son that now I am tired, you don’t need to worry about me. I didn’t know what to do before. (family 7, IP-mother, depression)

The atmosphere in the family meeting could also be charged with a lot of tension and emotions. Even if the parents knew what to say, the presence of and the support from the professionals was perceived as a security. Many parents stated that they could not have started to talk about the illness without the support.

It was so hard to talk with the children. Being a father who was supposed to be the stable man of the house and crying there in the family session. It was good that we had met him [the professional] before the family meeting so he knew what I wanted to say, so he could help me if I needed it. (family 11, IP-father, bipolar)

In summary, initiating communication about the mental illness was in some respects a demanding task for most of the parents, partly because of the feelings of guilt and shame and partly because of the difficulty of finding appropriate words and formulations to describe the illness to their children. The role of the professionals was emphasized and the confidence gained in them earlier in the process was an important facilitating factor, helping the parents to overcome the fear of being judged as parents.

Confidence and security – central category

Confidence and security was determined as the central category from the parents’ perception of the professionals and the FI as a method. It was crucial to further process, when parents started to talk about the mental illness with their children. Listening to the children’s experiences, finding the words and formulations for telling the children about the illness, and finally being able to start to talk about the illness in the family session required that there was a foundation of confidence and security for the parent. In several cases it could be seen how each step in this process strengthened the parent’s confidence and security and facilitated the next step. For example, a parent who doubted if his child would say anything in the interview felt pleased when the child had spoken openly and could receive the feedback from the professionals in a constructive way, even if some concerns about the child were presented. Evolving confidence and security were described by all parents except one, who had a diagnosis of a personality disorder. That parent had no positive experience of the method or the professionals and there was no further process of opening up communication within the family (Figure 1).

OPEN IN VIEWER

Figure 1.

The parents’ process of initiating communication about mental illness

Confidence and security – the alliance

The phenomenon of the parents’ confidence and security in the professionals and in the method appears to be close to the concept of therapeutic alliance, as used in the field of psychotherapy. The FI is not itself a psychotherapeutic intervention, but the setting resembles that used in short-term psychotherapy. Studies have also shown the importance of an alliance in general psychiatric care (Johansson, 2006) and the concept of alliance has become pan-theoretical. It thus appears to be reasonable to use the term alliance in this context.

The concept of alliance includes the client’s affective relationship with the therapist, the client’s motivation and ability to accomplish work collaboratively with the therapist, the therapist’s empathic responding to and involvement with the client, and the client’s and the therapist’s agreement about goals and tasks of therapy. The alliance is the most important single common factor in all psychotherapy, having a strong correlation to treatment outcome (Wampold, 2001). The severity of the problems and diagnostic group have no clear correlation to the establishment of alliance, even if there is a tendency for patients with borderline or other personality disorders to have more difficulties (Johansson and Eklund, 2006), probably due to interpersonal problems (Kernberg, 1993). This corresponds to the results of the present study with informants having varying diagnoses but a strong alliance emerging. The only exception was a parent with a diagnosis of borderline personality disorder.

The professionals’ contribution to the alliance has greater relative importance than that of the patients (Baldwin et al., 2007). Attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested and open were found to contribute to the alliance (Ackerman and Hilsenroth, 2003). In the present study the professionals were perceived as competent, but also as fellow human beings with a warm and supporting attitude, and the parents gained confidence in them. As mentioned before, respect for the parent is one of the principles in the FI. Elements such as transparency, adaptation to the family’s language and respecting the parents’ expertise are emphasized in the training of the professionals in order to contribute to a respectful attitude towards the parents.

The definition of alliance also includes agreement about the treatment goals and the means with which to reach the goals. A characteristic of the FI is a clear statement about the goal: it is the parents who in collaboration with the professionals define their specific goals. The goal of the FI is often basically obvious for the parents and they are provided a structured procedure for reaching that goal.

The structure and properties of the FI were perceived as very positive and well thought-out by the parents. They emphasized the importance of the two first sessions, when each parent had a session when it was their turn to be listened to. This corresponds to studies where clients report that the opportunity to talk about oneself and to be listened to and understood are helpful factors in their psychotherapy (Lilliengren and Werbart, 2005; Werbart et al., 2008). Listening to each others’ perspectives and getting an increased feeling of security before the interviews with the children during those two first sessions were important elements for the parents. Home visits, when children are included in the sessions, is a property of the FI that almost seemed to be a prerequisite for the further process, similar to previous findings (Pihkala and Johansson, 2008). The clear structure together with the flexibility of the FI contributed to a sense of control for the parents. Thus, the structure and properties of the FI appear to provide favourable conditions for collaboration between the parents and the professionals.

In summary, when assessing the FI from the perspective of alliance research, several features that enhance the positive alliance could be found. The strong alliance perceived by the parents may also be a partial explanation for the high degree of satisfaction with the FI expressed in the questionnaire-based studies about the method (Pihkala et al., 2010; Solantaus et al., 2009). This possible explanation is also mentioned in the study of the cultural adaptation of the method (d’Angelo et al., 2009).

As noted above, mental illness is surrounded by silence and stigma. It is especially difficult for a parent to start to talk about it with their children due to feelings of guilt. It is nevertheless striking how demanding it was for the parents to initiate communication about the illness. Studying the children of psychiatric patients has until now been a neglected area (Knutsson-Medin et al., 2007; Östman et al., 2005). One reason for this may have been the professionals’ perception that the issue of parenthood is too delicate for the parents. Because the FI seems to give a solid base of confidence and security for the parents, it might be a practicable method for psychiatric services when the needs of the patients’ children are to be met.

The codes found in the interviews of the IP- parents and NIP-parents were similar apart from those belonging to the subcategory ‘listening to the children’s experiences’, which were not found in the NIP-parent interviews. This indicates that the NIP-parents had fewer feelings of guilt and shame towards the children, which was also found in the questionnaire study (Pihkala et al., 2010), and that both had similar concerns about their children and difficulties in talking about the illness. The codes in the interviews of parents with different parental diagnoses in the family did not show any considerable variation.

Limitations

This study has several limitations. A considerable number of families invited to the study declined to participate and due to attrition within the families, the number of interviewed NIP-parents remained low. Also the total number of the interviewed parents is relatively small, which limits the transferability of the results. The low number of other diagnoses than depression may account for the similarity in the results across parents. A possible preconceptual bias because of the authors’ engagement in the method should also be kept in mind, but the interviewees perceived the interviewers as non-dependent from the professionals who had conducted the FI. In order to reduce the risk of bias, the interviews were held using dialogue that was as open and non-directive as possible and a conscious effort was made to perceive any negative aspects of the FI in the transcripts.