Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
Overview
The Issue
Despite the prevalence of parenthood among adults with mental illness, mental health systems have traditionally served individual patients through categorical funding streams that do not allow for family-focused services. Over the last decade, however, there has been increased attention to parents with mental illness and their children. In some cases, this increased awareness has led to the availability of funding and the development of innovative programs for parents with mental illness in the United States and elsewhere. Programs for parents have generally been developed on a small, local scale with limited funding, and have remained largely isolated from one another. As a result, we knew little about programs for parents or their impact on outcomes for adults and children. Before conclusions can be drawn about practices for parents with mental illness and their families, the development of an empirically supported evidence base is necessary.
The Current Project
Our goal in the current project was to take the next steps toward evidence-based practices for parents with mental illness and their families by identifying and systematically describing existing interventions. We report data from two studies. In the first study we identify programs and conduct in-depth telephone interviews with administrators and providers to describe, compare and contrast programs along selected dimensions. In the second study we define explicit logic models with hypothetical links between target populations, practices, processes, and outcomes for selected programs, using data obtained in comprehensive site visits.
Findings
Taken together, data from the two studies are used to identify core program components, key ingredients, and relevant outcomes. Core components include comprehensive family case management, access to a comprehensive array of services, coordination of multiple services and the facilitation of communication among multiple providers, flexible funds to meet unique family and individual needs, crisis intervention services, education about child development that enhanced parent-child relationships, and parenting skills training.
With respect to key ingredients, the data presented here indicate that family-centered, strengths-based values and practices may be the key to program success and improved outcomes for parents and children. Family-centered approaches posit the family as the unit of service, and optimal family functioning as the desired outcome. A family-centered approach is best served through the integration of adult and child services and systems, interagency collaboration, and the availability of non-categorical, flexible funding. The other key ingredient identified across programs was a trusting, emotionally supportive relationship between provider and consumer. Strengths-based, non-judgmental approaches, and unconditional care appeared to be the foundations for this relationship.
Finally, several relevant outcomes for rigorous program evaluation were also defined by the current studies. These included optimal functioning of both parent and child across role domains, improved parent-child relationship, preservation of family unit, achievement of basic family needs, enhanced social networks, and child-related outcomes such as school readiness, and school attendance. These outcomes are discussed with respect to strategies for assessment and methodological challenges.
Conclusions
Rigorous evaluation of programs for parents with mental illness will be possible only when the necessary resources and technical assistance are provided to support the standardization and manualization of current interventions. Research methods and tools must also be identified or developed that reflect participant and program goals and theories of change, capture program process and fidelity, and objectively measure meaningful outcomes related to adult, child, parent, and family functioning.
Site Visits
Five programs 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.
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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