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Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
Methods
Study I: The National Program Survey
The National Program Survey consisted of two parts. To identify existing programs, a mailing was sent in late 1998 to members of a large mailing list of programs and providers known to work with parents with mental illness (N = 300). This mailing list was developed by Nicholson and colleagues as part of the Parenting Options Project (POP). POP, funded by the National Institute on Disability and Rehabilitation Research from 1997 to 2000, focused on developing resources for parents with mental illness and their families, and providing technical assistance and consultation on the issues and needs of parents and their families. The mailing included a cover letter explaining that the investigators were interested in learning about any and all programs for parents with mental illness. Mailing list recipients were asked to complete and return an addressed and stamped postcard with contact information for any relevant programs or services for parents and their families.
Thirty-seven relevant card responses were received. Others wrote back describing related services, e.g., legal consultation services. These responses were supplemented with program data from a prior study of programs for parents with mental illness (Nicholson et al., 1993), and a concurrent survey of state mental health authorities about policies and program for parents (Nicholson, Biebel, Hinden, Henry, & Stier, 2000), to create a list of 53 known programs. Programs were categorized into high-, medium-, and low- specificity with respect to focus on parents with mental illness. "High-specificity" reflected programs developed for and targeted to meeting the needs of parents with mental illness. "Medium-specificity" reflected programs that provide parenting services but not specifically to parents with mental illness. Often parents with mental illness receive these services with other "at-risk" parents. The "low specificity" category included programs in which adults with mental illness participate, but services are not available to address their needs as parents.
An interview for program directors was developed to explore the following program characteristics: program development; program funding; theoretical orientation; target population; program goals; program models, services and interventions; and outcomes. Program directors were contacted by telephone, and an interview was scheduled with those who agreed to participate, or with their designees. All interviews were conducted on the telephone during the winter and spring of 1999. Initially, we intended to interview a representative from all programs. However, after several interviews with medium- and low-specificity programs, it became evident that comprehensive interviews were inappropriate for these respondents. A briefer interview reflecting program development, program funding, and services was developed for medium- and low-specificity programs. Interview data were coded for content and analyzed qualitatively. A logic model template was developed for use in Study II.
Study II: Site Visit Study
Qualitative analyses from Study I indicated that programs could be defined in terms of the following factors: Target population; theory and assumptions (including the programs' mission, theoretical orientation, assumptions, and goals); community context (such as the state and local political and economic environment, as well as the availability and accessibility of community collaborators); agency context (including such dimensions as agency philosophy, structure, resources, and staffing); program model (interventions and services); moderators; and outcomes.
In addition, interview data from Study I revealed that these program features could be related to each other as represented by the logic model in Figure 1. Target population in combination with theory and assumptions, and community and context influenced development of a program model and planned interventions and services. Program model and actual interventions, in combination with enhancing or obstructing moderators, determined outcomes. Moderators included both environmental conditions, e.g. local economy, and individual characteristics, e.g., severity of mental illness. The logic model defined by the National Program Survey was used to facilitate program description, and to delineate hypothesized links between target population, processes, practices, and outcomes for programs selected for site visits in Study II.
Five programs from the high-specificity group were selected for site visits in the spring and summer of 2000. Programs were selected to reflect diversity on three dimensions: geographic location, funding source, and program type or "model." Two or three investigators visited program sites for two to three days. During visits, interviews and discussions were conducted with program administrators, staff, participants, and community collaborators. Agency documents and budgets, e.g., annual reports and contracts, were reviewed. Data collection was organized around the logic model developed in Study I.
During the last day of the visit, investigators presented a draft of the logic model to program administrators and staff, and asked for feedback. Logic models were revised after the site visit and additional feedback from program staff and participants was requested and integrated via mail and telephone. Discussions with program staff and participants included explanation of the relationship of the logic model to building program evaluation efforts.
The following programs were selected for site visits:
Children and Parents Together (CAPT). CAPT is located in Commack, New York, a suburb of New York City. CAPT is funded primarily by non-categorical state mental health dollars and Medicaid "re-investment" dollars. Parents receive support through case management and psychoeducational support groups. Children ages 0 to 3 years participate in a therapeutic nursery program.
Emerson Davis Family Development Center. The Emerson Davis Center is located in Brooklyn, NY. Residential case management services for parents with mental illness and their children aged 0 to 12 years are provided. Primary funding for Emerson Davis comes from the state Office of Mental Health and HUD grants made available for services for homeless people with mental illness in the city of New York (New York/New York program).
Family Support Services/PACE Program (FSS/PACE). FSS/PACE is located in Iowa City, IA. FSS/PACE uses a clinical case management model to provide services to parents with mental illness and their children. Children may be any age as long as they are living with their parents. State mental health block grants and reimbursement for clinical services support FSS/PACE.
Invisible Children's Program (ICP). ICP is located in Orange County, NY, a large rural area approximately 100 miles north of New York City. ICP provides family case management services for parents with mental illness and their children. ICP relies on the New York State Office of Mental Health for primary funding.
San Francisco General Hospital Programs. Three programs in the Department of Psychiatry at the San Francisco General Hospital were chosen to reflect a continuum of co-existing services. The Consultation/Liaison Program to OB/GYN (C/L program) in the Department of Psychiatry provides outpatient and inpatient psychiatric services to pregnant and postpartum women with mental illness. The program is funded by state contracts with the Department of Psychiatry, and clinical reimbursement from the state health insurance program, MediCAL. The Infant Parent Program (IPP) provides parent-child psychotherapy for families in which children are at risk for developmental problems. IPP receives funding through the Departments of Psychiatry at San Francisco General Hospital and the University of California at San Francisco, as well as from MediCAL. The Women's Issues Psychiatric Program is an inpatient psychiatric program with a focus on gender and reproductive issues for women with mental illness. It is a multi-disciplinary program funded by state mental health contracts with the Department of Psychiatry at San Francisco General Hospital, and MediCAL.
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