Profession Differences in Family Focused Practice in the Adult Mental Health System

There is a large gulf between what psychiatric services should (or could) provide and what they do in practice. This article sought to determine practice differences between the differing professions working in adult mental health services in terms of their family focused work. Three hundred and seven adult mental health professionals completed a cross‐sectional survey of family focused practices in adult mental health services. Findings highlight that social workers engaged in more family focused practice compared to psychiatric nurses, who performed consistently the lowest on direct family care, compared to both social workers and psychologists. Clear skill, knowledge, and confidence differences are indicated between the professions. The article concludes by offering direction for future profession education and training in family focused practices.     

Scaling Up Family Therapy in Fragile,Conflict‐Affected States

This article discusses the design and delivery of two international family therapy‐focused mental health and psychosocial support training projects, one in a fragile state and one in a post‐conflict state. The training projects took place in Southeast Asia and the Middle East/North Africa. Each was funded, supported, and implemented by local, regional, and international stakeholders, and delivered as part of a broader humanitarian agenda to develop human resource capacity to work with families affected by atrocities. The two examples illustrate how task‐shifting/task‐sharing and transitional justice approaches were used to inform the scaling‐up of professionals involved in each project. They also exemplify how state‐citizen phenomena in each location affected the project design and delivery.     

In Our Lives and Under Our Skin: An Investigation of Specific Psychobiological Mediators Linking Family Relationships and Health Using the Biobehavioral Family Model

The objective of this study was to use the Biobehavioral Family Model (BBFM) to delineate which psychophysiological variables link romantic and family relationship satisfaction variables to health outcomes. Data from individuals who reported being partnered from the second wave of the National Survey of Midlife Development in the United States (MIDUS II), Project 4 (n = 812) were used to test a structural equation model which explored which psychophysiological variables potentially mediated associations between positive and negative family emotional climate variables and disease activity. This model found that current and past family variables had larger associations with the psychophysiological variables than romantic partner variables; depressive symptoms, anxiety, and inflammation partially mediated associations between family relationships and health; and, contrary to the hypotheses, romantic partner and family support were linked to worse health outcomes. However, the findings should be viewed with regard to the cross‐sectional design of the study. Overall, the findings support the use of the BBFM as a model that can guide clinical interventions.     

Global Mental Health: A Call for Increased Awareness and Action for Family Therapists

Global mental health (GMH) is an emerging field that focuses on the need for culturally sensitive mental health services in low‐ and middle‐income countries (LMICs). While many new initiatives have been established worldwide to understand GMH needs and to provide care in LMICs, family therapists have primarily worked with families in high‐income countries. The few existing family‐based initiatives in GMH focus on psychoeducation and are typically not based on general systems theory. However, emerging trends in family therapy may enable family therapists to impact mental health issues in LMICs. These trends, which are shared interests of both family therapy and GMH, include collaborative care, a growing emphasis on the importance of culture in understanding and treating mental health issues, recognition of the ability of families to support or impede recovery from mental illness, and the use of strength‐based and evidence‐based treatments. This paper describes ways for family therapists to become active in the GMH community.     

Preparing the Field for Feasibility Testing of a Parenting Intervention for War‐Affected Mothers in Northern Uganda

In this article, we discuss the successful implementation of an adapted evidence‐based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long‐term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance‐use disorders. The processes described here cover a 4‐year period culminating in the implementation of the nine‐session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.     

Clinical Guidelines for Working With Stepfamilies: What Family,Couple, Individual,and Child Therapists Need to Know

This article draws on four decades of research and clinical practice to delineate guidelines for evidence‐informed, clinically sound work with stepfamilies for couple, family, individual adult, and child therapists. Few clinicians receive adequate training in working with the intense and often complex dynamics created by stepfamily structure and history. This is despite the fact that stepfamilies are a fundamentally different family form that occurs world‐wide. As a result many clinicians rely on their training in first‐time family models. This is not only often unhelpful, but all too often inadvertently destructive. The article integrates a large body of increasingly sophisticated research about stepfamilies with the author's four decades of clinical practice with stepfamily relationships. It describes the ways in which stepfamilies are different from first‐time families. It delineates the dynamics of five major challenges stepfamily structure creates: (1) Insider/outsider positions are intense and they are fixed. (2) Children struggle with losses, loyalty binds, and change. (3) Issues of parenting, stepparenting, and discipline often divide the couple. (4) Stepcouples must build a new family culture while navigating previously established family cultures. (5) Ex‐spouses (other parents outside the household) are part of the family. Some available data are shared on the impact of cultural and legal differences on these challenges. A three‐level model of clinical intervention is presented: Psychoeducational, Interpersonal, and Intrapsychic/Intergenerational Family‐of‐Origin. The article describes some “easy wrong turns” for well‐meaning therapists and lists some general clinical guidelines for working with stepfamily relationships.     

Factors Impacting the Mental Health of the Caregivers of Children with Asthma in China: Effects of Family Socioeconomic Status,Symptoms Control,Proneness to Shame,and Family Functioning

Caregiver mental health is widely considered to be an important factor influencing children's asthma symptoms. The present study aimed to examine key factors that contribute to caregiver mental health in pediatric asthma with a Chinese sample. Two hundred participants reported their family socioeconomic status (SES), proneness to shame, asthma symptoms control of their child, family functioning, and their depression and anxiety symptoms. Results suggested that low family SES, low family functioning, and a high level of shame proneness were associated with high levels of anxiety and depression for caregivers. Family functioning mediated the effects of SES and shame on caregiver mental health and also moderated the effects of SES and shame on caregiver depression. This study highlights the importance of reducing experience of shame and enhancing family functioning in families affected by pediatric asthma.     

Relationship between Mental Health and Burden among Primary Caregivers of Outpatients with Schizophrenia

There is growing recognition that caring for a patient with schizophrenia often results in high levels of perceived burden and poorer overall mental health for caregivers. A quantitative cross‐sectional design and standardized instruments were used to collect data from 355 primary caregivers of adults in outpatient care with schizophrenia in China. Structural equation modeling was used to examine the association between caregiver burden and mental health among primary caregivers and whether this association is influenced by personality, coping style, and family functioning, based on a diathesis–stress perspective. Goodness‐of‐fit indices (χ²/df = 1.406, GFI = 0.919, CFI = 0.957, etc.) confirmed that the modified model fit the data well. In line with the diathesis–stress model, and with this study's hypotheses, we found that caregiver burden was significantly related to mental health outcomes directly. The final model showed that personality traits, coping style, and family function influenced the relationship between caregiver burden and mental health. The neuroticism personality traits have a direct effect on caregiver burden and family functioning in this sample. Coping style had a direct effect on the caregiver burden, and family functioning had a direct effect on the caregiver burden. Our final model about primary caregivers can be applied clinically to predict mental health outcomes from caregiver burden.     

Voices of Dialogue and Directivity in Family Therapy With Refugees: Evolving Ideas About Dialogical Refugee Care

In this article, we reflect on our evolving ideas regarding a dialogical approach to refugee care. Broadening the predominant phased trauma care model and its engaging of directive expertise in symptom reduction, meaning making, and rebuilding connectedness, these developing dialogical notions involve the negotiation of silencing and disclosure, meaning and absurdity, hope and hopelessness in a therapeutic dialogue that accepts its encounter of cultural and social difference. In locating therapeutic practice within these divergent approaches, we argue an orientation on collaborative dialogue may operate together with notions from the phased trauma care model as heuristic background in engaging a polyphonic understanding of coping with individual and family sequelae of forced displacement. This locating of therapeutic practice, as informed by each perspective, invites us to remain present to fragments of therapeutic positioning that resonate power imbalance or appropriation in a therapeutic encounter imbued with a social context that silences refugees’ suffering. In a clinical case analysis, we further explore these relational complexities of negotiating directive expertise and collaborative dialogue in the therapeutic encounter with refugee clients.     

IMPLEMENTATION OF AN EVIDENCED‐BASED PARENTING PROGRAM IN A COMMUNITY MENTAL HEALTH SETTING

The process of mental health intervention implementation with vulnerable populations is not well‐described in the literature. The authors worked as a community‐partnered team to adapt and pilot an empirically supported intervention program for mothers of infants and toddlers in an outpatient mental health clinic that primarily serves a low‐income community. We used qualitative ethnographic methods to document the adaption of an evidence‐based intervention, Mothering from the Inside Out, and the pilot implementation in a community mental health clinic. Seventeen mothers and their identified 0‐ to 84‐month‐old children were enrolled in the study. Key lessons from this implementation include (a) the importance of formative work to build community relationships and effectively adapt the intervention to meet the needs of the therapists and their clients, (b) the importance of designing plans for training and reflective supervision that fit within the flow of the clinic and can tolerate disruptions, and (c) that use of an interdisciplinary approach is feasible with the development of a plan for communication and the support of a trained reflective clinical supervisor. These key lessons advance the scientific knowledge available to healthcare managers and researchers who are looking to adapt mental health clinical interventions previously tested in clinical trials to implementation in community settings.     

Changes in Families’ Caregiving Experiences through Involvement as Participants then Facilitators in a Family Peer‐Education Program for Mental Disorders in Japan

A family peer‐education program for mental disorders was developed in Japan, similar to existing programs in the United States and Hong Kong. Families that serve as facilitators in such programs may enhance their caregiving processes and, thereby, their well‐being. This study's aim was to describe how families’ caregiving experiences change, beginning with the onset of a family member's mental illness, through their involvement in a family group or peer‐education program as participants then facilitators. Thus, this study was conducted in a family peer‐education program for mental disorders in Japan. Group interviews were conducted with 27 facilitators from seven program sites about their experiences before, during, and after becoming facilitators. Interview data were coded and categorized into five stages of caregiving processes: (1) withdrawing and suppressing negative experiences with difficulty and regret; (2) finding comfort through being listened to about negative experiences; (3) supporting participants’ sharing as facilitators; (4) understanding and affirming oneself through repeated sharing of experiences; and (5) finding value and social roles in one's experiences. The third, fourth, and fifth stages were experienced by the facilitators. The value that the facilitators placed on their caregiving experiences changed from negative to positive, which participants regarded as helpful and supportive. We conclude that serving as facilitators may improve families’ caregiving processes.     

Review of Family Relational Stress and Pediatric Asthma: The Value of Biopsychosocial Systemic Models

Asthma is the most common chronic disease in children. Despite dramatic advances in pharmacological treatments, asthma remains a leading public health problem, especially in socially disadvantaged minority populations. Some experts believe that this health gap is due to the failure to address the impact of stress on the disease. Asthma is a complex disease that is influenced by multilevel factors, but the nature of these factors and their interrelations are not well understood. This paper aims to integrate social, psychological, and biological literatures on relations between family/parental stress and pediatric asthma, and to illustrate the utility of multilevel systemic models for guiding treatment and stimulating future research. We used electronic database searches and conducted an integrated analysis of selected epidemiological, longitudinal, and empirical studies. Evidence is substantial for the effects of family/parental stress on asthma mediated by both disease management and psychobiological stress pathways. However, integrative models containing specific pathways are scarce. We present two multilevel models, with supporting data, as potential prototypes for other such models. We conclude that these multilevel systems models may be of substantial heuristic value in organizing investigations of, and clinical approaches to, the complex social–biological aspects of family stress in pediatric asthma. However, additional systemic models are needed, and the models presented herein could serve as prototypes for model development.     

Parentification,Stress, and Problem Behavior of Adolescents who have a Parent with Mental Health Problems

When adolescents live with a parent with mental illness, they often partly take over the parental role. Little is known about the consequences of this so‐called parentification on the adolescents' internalizing and externalizing problems. This survey study examined this effect cross‐sectionally and longitudinally in a sample of 118 adolescents living with a parent suffering from mental health problems. In addition, the study examined a possible indirect effect via perceived stress. Path analyses were used to examine the direct associations between parentification and problem behavior as well as the indirect relations via perceived stress. The results showed that parentification was associated with both internalizing and externalizing problems cross‐sectionally, but it predicted only internalizing problems 1 year later. An indirect effect of parentification on adolescent internalizing and externalizing problems via perceived stress was found, albeit only cross‐sectionally. These findings imply that parentification can be stressful for adolescents who live with a parent with mental health problems, and that a greater awareness of parentification is needed to prevent adolescents from developing internalizing problems.     

Mid‐ and Long‐Term Effects of Family Constellation Seminars in a General Population Sample: 8‐ and 12‐Month Follow‐Up

In a previous randomized controlled trial (RCT), short‐term efficacy of family constellation seminars (FCSs) in a general population sample was demonstrated. In this article, we examined mid‐ and long‐term stability of these effects. Participants were 104 adults (M = 47 years; SD = 9; 84% female) who were part of the intervention group in the original RCT (3‐day FCS; 64 active participants and 40 observing participants). FCSs were carried out according to manuals. It was predicted that FCSs would improve psychological functioning (Outcome Questionnaire OQ‐45.2) at 8‐ and 12‐month follow‐up. Additionally, we assessed the effects of FCSs on psychological distress, motivational incongruence, individuals’ experience in their personal social systems, and overall goal attainment. Participants yielded significant improvement in psychological functioning (d = 0.41 at 8‐month follow‐up, p = .000; d = 0.40 at 12‐month follow‐up, p = .000). Results were confirmed for psychological distress, motivational incongruence, the participants’ experience in their personal social systems, and overall goal attainment. No adverse events were reported. This study provides first evidence for the mid‐ and long‐term efficacy of FCSs in a nonclinical population. The implications of the findings are discussed.     

Relationship Distress as a Mediator of Adverse Childhood Experiences and Health: Implications for Clinical Practice with Economically Vulnerable Racial and Ethnic Minorities

Adverse childhood experiences (ACE) are interpersonal sources of distress negatively correlated with physical and mental health, as well as maladaptive intimate partner conflict strategies in adulthood. Economically vulnerable racial and ethnic minorities report the greatest disparities in exposure to ACE, as well as relationship distress and health. Yet, little is known about the connections between ACE, relationship distress, and health. We therefore tested a theoretical model for the mediating role of relationship distress to explain the ACE‐health connection with a sample (N = 96) predominantly racial/ethnic minorities (87%) with low income. We applied partial least squares structural equation modeling with bootstrapping (N = 500). Relationship distress strengthened the predictive relationship between ACE and health, and accounted for 42% of the variance in health. The results provide preliminary support for relationship distress as a social determinant of health disparities with implications for interdisciplinary health intervention.