Family Support Groups for Family Members of Mentally Ill Offenders: Family Expectations and Experiences

Introduction

In Belgium, mentally ill offenders are simultaneously considered as a potential danger to society (“offenders”) and as a person who needs treatment and care (“patients”), for which they are placed under an “internment measure” (Vandevelde et al., 2011). Since October 1, 2016, The Law on Internment of Mentally Ill Offenders (May 5, 2014, amended by the Potpourri III-law of May 4, 2016) came into force, describing the measure of “internment” as “a safety measure to protect society and that simultaneously aims to ensure that the mentally ill offender is provided with the care his/her condition requires in view of his/her reintegration into society” (Casselman, De Rycke, Heimans, & Verpoorten, 2017; Heimans, Vander Beken, & Schipaanboord, 2015, p. 1051). This Law states that persons can be subjected to an internment measure: (a) if their criminal offense harms the psychical and psychological integrity of a third party, (b) if they have a mental illness at the time of the offense, and (c) if there is a danger of committing new offenses. The internment measure can be enforced for an unlimited period in time (Casselman et al., 2017; Vander Beken, Heimans, & Schipaanboord, 2016). Internationally, a large number of studies have addressed the challenges that mentally ill offenders are confronted with, their recovery process and the shift from a burden-oriented perspective toward more strengths-based approaches (e.g., Aga, Vander Laenen, Vandevelde, Vermeersch, & Vanderplasschen, 2017; Barnao & Ward, 2015; Robertson, Barnao, & Ward, 2011). However, it is important to be aware that not only the mentally ill offenders, but also their social network (more in particular their family members) are confronted with both a relative’s mental illness and criminal offense, causing different emotional, social and psychological burdens (Rowaert et al., 2016; Rowaert, Vandevelde, Lemmens & Audenaert, 2017; Tsang, Pearson, & Yuen, 2002). Raised levels of stress are mentioned by the family members, because of the violence within the family, the double stigmatization and the disintegration of family relationships (Absalom-Hornby, Gooding, & Tarrier, 2011; Ferriter & Huband, 2003; James, 1996; McCann, McKeown, & Porter, 1996; Pearson & Tsang, 2004; Tsang et al., 2002). Yet, many of these family members—the majority of whom are parents—take on an ongoing caregiving role for which they often feel unprepared (Corsentino, Molinari, Gum, Roscoe, & Mills, 2008; Marsh & Johnson, 1997; Wynaden, 2007). About 70% of mentally ill offenders residing in a forensic psychiatric setting in (Northwest) England and Wales have contact with their family members and 56% of them is involved in the discharge planning (Absalom, McGovern, Gooding, & Tarrier, 2010; Canning, O’Reilly, Wressell, Cannon, & Walker, 2009). But, many often lack sufficient support from friends, family members or professionals, and thus have little opportunities to disclose their concerns such as who will take care of their relative in the future (Corsentino et al., 2008; MacInnes & Watson, 2002; Nordström, Kullgren, & Dahlgren, 2006). Moreover, many family members are in need for information, peer support and recognition (Nordström et al., 2006; Ridley et al., 2014; Rowaert et al., 2017).

The last decade, research has focused on the role of social network members in relation to offender risk assessment and management (Pomp, Spreen, Bogaerts, & Völker, 2010) and the prevention of crime (Martin, 2002; Oberwittler, 2004). Several studies have shown that increased levels of social support are associated with a reduction in criminal behavior (Colvin, Cullen, & Vander Ven, 2002; Cullen, 1994; Nakhaie & Sacco, 2009; Pflueger, Franke, Graf, & Hachtel, 2015). In forensic psychiatric settings, Forensic Social Network Analysis (FSNA) is used to define social relationships in terms of risk (and severity) of recidivism (Pomp et al., 2010; Ter Haar-Pomp, Spreen, Bogaerts, & Völker, 2015). Yet, it is crucial to differentiate between positive social (e.g., stable friendships) and risk-increasing resources (e.g., friends lacking social skills) (see e.g., Bolger, Zuckerman, & Kessler, 2000; Resnick, Ireland, & Borowsky, 2004). Based on the results of FSNA, interventions matching with the risk profile of the patient can be selected (ter Haar-Pomp, de Beer, van der Lem, Spreen, & Bogaerts, 2015). Family treatment programs addressing the relationship and the normative dimensions of family therapy (e.g., Functional Family Therapy [FFT] or Multisystemic Therapy [MST]) have positive effects on the reduction of antisocial behaviour of delinquents (Andrews & Bonta, 2010). Absalom and colleagues (2010) stated that “frequent contact between families and patients, and in this population between families and the forensic services, is a prerequisite for family interventions” (p. 358). Although social support and family interventions are considered to be essential, there is a dearth of family interventions in forensic psychiatric settings (Absalom-Hornby, Hare, Gooding, & Tarrier, 2012). Studies conducted in England and Wales show that a minority of medium secure settings make family therapy available for family members of mentally ill offenders (Absalom et al., 2010; Davies, Mallows, Easton, Morrey, & Wood, 2014; Geelan & Nickford, 1999). Barriers to introducing family interventions in these settings are the fixed and inappropriate visiting hours, the limited contact with and engagement of family members and the lack of sufficiently trained staff members (Absalom-Hornby et al., 2012; Davies et al., 2014; Geelan & Nickford, 1999). However, secure settings do not only focus on family interventions, but also connect with family members in other ways to “bridge the gap between the unit and the community,” as Davies and colleagues (2014, p. 527) have stated. Examples include “Family and Friends days, advocacy services, increasing the contact with families at the point of the patients’ admission via ‘welcome meetings’ and ‘family link meetings’” (Davies et al., 2014, pp. 527-528).

Only recently, Family Support Groups (FSGs) have been developed for family members of mentally ill offenders and aim to support them in dealing with both the relative’s mental illness and the internment measure (Rowaert, Hanssens, Audenaert, Vandevelde, & Lemmens, submitted). These FSGs were held on a neutral location, without the involvement of the patients and a forensic psychiatric setting. An FSG is subdivided into four sessions, each consisting of a particular prescribed theme: Session 1 focuses on self-care of the family members, Session 2 on who is going to take care of their relative in the future, Session 3 on their strengths and capabilities for coping with the situation, and Session 4 is a reflection of the previous sessions. Furthermore, homework assignments are given after each session to have the participants reflect upon the previous themes and the effect on their own lives (Rowaert et al., submitted).

FSGs are conceptually based on systemic Multi-Family Group therapy (MFG) format, which is adapted to a forensic context (Rowaert et al., submitted). MFGs aim to bring families together to reduce stigma and enable participants to expand their social network, as they have become socially isolated because of the situation (Asen, 2002; Asen, Dawson, & McHugh, 2001; McFarlane, 2002). The therapists take on the role of catalyst to help family members connect with each other. In this respect, peer support is very powerful and can promote change, as family members are seen as advisors to one another (Asen, 2002; Asen & Schuff, 2006; McFarlane, 2002). Family members can indirectly learn from each other by being provided psycho-education and mutual support and feedback (Asen et al., 2001; McFarlane, 2002).

A process-pilot study investigating the outcomes of FSG’s has shown that families experience less self-blame as they could learn from and observe others, have greater emotional well-being because they received support from the group, and experience less loss of control over their lives by feeling similar to others and seeing the universality of the problems (Rowaert, Vandevelde, Audenaert, & Lemmens, submitted after revision; Rowaert, Vandevelde, Audenaert & Lemmens, 2018). Furthermore, therapeutic factors regarding relational climate (e.g., group cohesion, support from group, confidence in therapists) were considered to be particularly helpful from the start of the sessions; whereas therapeutic factors such as expressing and experiencing positive feelings, forgetting one’s own problems through helping others, hope from seeing progress in others, guidance from therapists, and getting interpersonal feedback gradually increased over the various sessions (Rowaert et al., 2018).

Although the quantitative studies examined specific helpful therapeutic factors, less is known about the expectations and experiences of family members before and after attending family group therapy. Nonetheless, it is important to “give voice” to family members through qualitative interviews, because there is a need for more profound research on treatment expectations and experiences before and after attending family group therapy (Tighe, Pistrang, Casdagli, Baruch, & Butler, 2012). To our knowledge, this has only been studied within MST and FFT research, which are different from MFG as these family therapies focus on adolescents’ antisocial behaviors. More specific, MST is a family and community-based treatment that empowers family members to obtain resources to cope with adolescents’ antisocial behavior such as substance abuse and criminal offenses (Henggeler & Schaeffer, 2016; Kaur, Pote, Fox, & Paradisopoulos, 2017; Sheridan, Peterson, & Rosen, 2010). FFT is an evidence-based family therapy treatment for adolescents with behavioral problems and their families—it focuses on understanding familial relationships and developing adaptive behaviors that can change maladaptive ones (Hartnett, Carr, Hamilton, & Sexton, 2017; Robbins, Alexander, Turner, & Hollimon, 2016). Although these results are not generalizable to our research context as such—because some aspects are specifically linked to the MST or FFT context—they are important to mention because no other research is available (Hartnett et al., 2017; Kaur et al., 2017). Researchers report that families were reluctant at the beginning, as they were tired, stressed, and felt that they had already tried everything (Tighe et al., 2012). When asked about expectations, they mainly inquired about what was going to happen (Sheridan et al., 2010). When taking part in the family therapy intervention, many family members appreciated the new ideas and the concrete advice they were given, their increase in reflection, the changes in their beliefs, and the improvements in their family functioning (e.g., parenting and communication skills) (Hartnett et al., 2017; Kaur et al., 2017; Tighe et al., 2012). Family members felt heard and supported by the therapists and liked their guidance, as they were empathic, understanding, and sincere. The nonblaming, sincere and encouraging approach used by the therapists led to feelings of being respected and accepted, which created stronger self-confidence and improved mental well-being, and reintroduced hope into the lives of the participants. Through therapy, participants become more resilient and unburdened, as it provides a safe place to ask questions and exchange experiences (Asen & Schuff, 2006; Hartnett et al., 2017; Kaur et al., 2017; Sheridan et al., 2010; Tighe et al., 2012).

Family members’ treatment expectations and experiences are important for identifying potential problems or limitations of an intervention, and they can provide insight into how it can be improved in the future (Tighe et al., 2012). The present study focused on treatment expectations and experiences of family members before and after attending an FSG. The study considers the views of family members with regard to the changes the FSG brought into their lives.

Method

Data Analysis

In this study, it was considered important to “give voice” to the treatment expectations and experiences of family members who attended an FSG. A qualitative research method was chosen to represent the richness and the complexity of the family members’ lived experiences (Elliott, 2010; Pistrang & Barker, 2010). The pre- and posttreatment in-depth interviews were transcribed verbatim and analyzed using Nvivo 11 (QSR International Pty Ltd, 2015). Thematic analysis was used, because it is “a method for identifying, analysing, and reporting patterns (themes) within data. It minimally organises and describes your data set in rich detail” (Braun & Clarke, 2006, p. 6; Pistrang & Barker, 2010). An inductive approach was used to derive themes closely linked to the data (Braun & Clarke, 2006, 2012; Mortelmans, 2011), which was important as this study aimed at capturing the expectations and experiences of family members who participated in an FSG. The first author of this research paper analyzed the data of both pre- and posttreatment separately, by using an open coding process closely linked to what the family members said. Afterwards, these codes were generated to (a) pretreatment themes (e.g., emotions, support, general prospects) and (b) posttreatment themes (e.g., quality of the treatment, emotions, experiences, lessons learned from the sessions, roles in the group, and homework assignments) to form two separate tree structures which were discussed with the coauthors of this study. The analysis was subdivided into two domains—(a) expectations and (b) experiences—each generating four themes (see Table 1).

OPEN IN VIEWER

Table 1.

Expectations and Experiences of Family Members Participating in an FSG.

Expectations before the start		Experiences after the intervention
Curiosity or hesitation about taking part in the FSG		Feelings of satisfaction and relief
Peer support and experiencing universality of problems		Communality and support
Receiving and giving advice and information		Gaining new insights
Safety and respect		Group-specific characteristics • Group guidance • Group organization • Homework assignment • Heterogeneity of the group

Note. FSG = Family Support Group.

Results

Discussion

This study investigated the treatment expectations and experiences of family members of mentally ill offenders attending a FSG. Many family members were curious about what the FSG was about before it started. Only a few mentioned that they hesitated a while, due to practical or emotional reasons. This differs from the study of Tighe and colleagues (2012), because they report that family members were at first reluctant to participate in a family intervention because they were stressed, tired and had the feeling that they had already tried everything. This can be due to the fact that family members in this study already had a long history of coping with their relative’s mental illness and the internment measure. Moreover, for the greater part, family members were selected from nonprofit organizations that organize activities for family members, which could have made it easier for these family members to participate in the FSG. Another explanation could be that an FSG aims to support and empower family members without the mentally ill persons being involved. This differs from an MFG, which aims to help the patient in his or her recovery process by engaging family members in the treatment and rehabilitation (McFarlane, 2002).

The results show that, at the end of the four sessions, family members had a satisfied feeling, as their (limited) expectations were fulfilled (see Table 1). Yet, it is noteworthy that most of their expectations (experiencing universality of problems, peer support, and receiving advice and information) were in line with the difficulties (double stigma, social isolation, and no or incorrect information) they had experienced in the years before (Nordström et al., 2006; Tsang et al., 2002; Rowaert et al., 2017). Looking at the experiences, the same trend can be observed, as family members valued the communality, the support from the group, and gaining new insights. The latter helped them to reflect upon their lives and the lives of their relatives, which was developed further in the homework assignments. The homework assignment about taking care of their relative in the future was considered especially important, because many family members had never planned for what will happen to their relative when they are no longer around (Corsentino et al., 2008).

In the interviews, family members mainly mention therapeutic factors considering the relational climate of the FSG, as they talk about support from the group, communality, and the confidence they have in the therapists. This is in line with previous quantitative research reporting that group cohesion, universality of problems, and similarity with others are important from the start of the FSG (Rowaert et al., 2018). Experiencing communality is regarded as important by many family members—not only confronted with a relative’s mental illness—because they want to meet persons dealing with similar situations, as that is destigmatizing and helps build up a social network (Asen, 2002; Asen & Schuff, 2006; McFarlane, 2002). Family members of mentally ill offenders are often socially, emotionally, and psychologically burdened due to the situation they are confronted with—and attending an FSG creates for them the opportunity to talk to other family members in a safe and supportive environment, which can improve their emotional well-being (Asen & Schuff, 2006; McFarlane, 2002; Tsang et al., 2002). Family members can observe others and indirectly learn from their behavior and coping strategies, which in a way is also supportive, as this helps reduce their self-blame and rebuilds self-confidence (Lemmens et al., 2003; McFarlane, 2002; Rowaert et al., submitted after revision). Furthermore, family members develop feelings of solidarity and experience less loss of control over their lives, because participants inspire each other by informal psycho-education and sharing experiences (Asen, 2002; Asen & Schuff, 2006; Rowaert et al., submitted after revision).

Furthermore, this study highlights the important role of the therapists within an FSG. Their respectfulness and understanding are especially highly valued. Many family members often experienced these values with professionals for the first time, as previously they had been confronted with mental health care workers or psychiatrists who did not want to listen to their story or involve them in the treatment of their relative (MacInnes & Watson, 2002; Nordström et al., 2006; Rowaert et al., 2017). Also, in other MFG research studies, the nonblaming and encouraging approach of therapists is considered to be very important (Sheridan et al., 2010; Tighe et al., 2012). Thanks to this, a therapy group can become a safe place for family members to exchange experiences, observe others, and change their beliefs (Sheridan et al., 2010).

Based on the idea of social support and its risk-reducing effect on criminal behavior, studies acknowledge the importance of involving the social network of the patient (i.e., family members) in forensic psychiatric treatment (Colvin et al., 2002; Cullen, 1994; Pomp et al., 2010; ter Haar-Pomp et al., 2015). From this perspective, the FSG is helpful in supporting family members to engage in relationships with their offending relative. An important avenue for future research is to examine the influence of the FSG on recidivism rates of mentally ill offenders. Yet, the difficulties mental health professionals are confronted with—such as professional confidentiality vis-à-vis the mentally ill person, and how they can involve family members—will be important to explore further. This involves that mental health professionals will need to balance between the interests of the patients and those of family members in treatment and care. In this perspective, the idea of a shared partnership, with professionals working together with patients and their families, based on the concept of relational recovery, is important, especially in the light of strengths-based approaches. Relational recovery considers the need to move beyond “individual journeys” and places emphasis on the development of interpersonal acts within offender therapeutic and family therapeutic research (Price-Robertson, Obradovic, & Morgan, 2017). A shared partnership accepts the complexity of people’s lives and of our society, in which concepts like social integration, inclusive citizenship and socialization are amply present (Dewaele et al., 2015). Shared partnerships, however, are still challenged by barriers in the health care system (e.g., patient confidentiality regulations) and barriers relating to family contact (e.g., disruptiveness, poor contact and over-involvement) (Quah, 2017). In our view, professionals should further be encouraged to (re)think and reflect on the vision of their setting with regard to the involvement of, and mutual collaboration with family members (Riebschleger, 2005).

As this is a pilot study, the results are not generalizable, and some limitations of the study need to be mentioned. First of all, the study consists of 2 FSG cycles, with only 17 participants engaged in the complete duration of the FSG. Based on the inclusion criteria, many participants are selected from nonprofit organizations for family members of mentally ill persons, which could have biased the results. The small sample size can also be explained by the fact that some family members do not express a need to participate in an FSG because they have enough support or have the feeling they can cope with the situation they face. Although the FSG is created as a supportive and empowering treatment for family members, the format can also generate a barrier to participation by family members, because they do not want to be regarded by therapists as “second patients” who are in need of treatment. Second, the experiences of family members can be biased, as most of them had a long-standing history with mental health care and had already developed some coping strategies. Third, by only focusing on empowering and supporting family members, the study did not (yet) investigate if attending an FSG may have an influence on the situation and rehabilitation of the mentally ill offenders.

To conclude, this study shows that family members are in need for information and collaboration with professionals. They look for advice and new pathways to improve the situation of their relative. Therefore, this study is important in understanding family treatment expectations and experiences toward a FSG. Future family groups should focus on communality, peer support, and differences in family and gender roles, as the latter was important for many family members to experience solidarity through a heterogeneity of family roles. Therapists will play an important role, guiding the group toward gaining new insights and experiencing positive feelings, like satisfaction and energy. Moreover, homework assignments can help by having family members further reflect upon certain themes being discussed within the group. Future research about FSG should pay attention to different psychiatric disorders, as the hypothesis is raised as to whether other family members experience the same therapeutic factors as helpful. Furthermore, future research should also try to include family members who do not have a long-standing history of taking care of their relative, by trying to contact family members who have only recently been confronted with the mental illness and/or the criminal offense of their relative.