Apr 25, 2008 - ACT Center of Indiana, Indianapolis, IN, USA ... phone call to the CSP directors was made to further ..... (1) Number of months in current job.
Community Ment Health J (2008) 44:337–345 DOI 10.1007/s10597-008-9135-x
ORIGINAL PAPER
Attitudes and Perceived Barriers to Working with Families of Persons with Severe Mental Illness: Mental Health Professionals’ Perspectives Hea-Won Kim Æ Michelle P. Salyers
Received: 5 March 2007 / Accepted: 4 March 2008 / Published online: 25 April 2008 Ó Springer Science+Business Media, LLC 2008
Abstract A state-wide survey of 453 clinicians serving people with severe mental illness in community mental health centers evaluated the degree to which they provide services to families and their perceptions of barriers to developing such services. Most clinicians did not provide many services to families and reported barriers related to the family or client (e.g., family’s lack of interest) and their own work environment (e.g., heavy workload). Clinicians who had received prior training on working with families provided more services, had more positive attitudes toward family, and felt more competent about their knowledge, confirming the importance of staff training. Keywords Family services Training Barriers Providers’ perspectives Severe mental illness
H.-W. Kim (&) School of Social Work, Indiana University, 902 W. New York St., Indianapolis, IN 46202, USA e-mail: heakim@iupui.edu M. P. Salyers Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA M. P. Salyers ACT Center of Indiana, Indianapolis, IN, USA M. P. Salyers VA HSR&D Center on Implementing Evidence-based Practice, Roudebush VAMC, Indianapolis, IN, USA M. P. Salyers IU Center for Health Services & Outcomes Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
Introduction Beginning in the 1950s, deinstitutionalization in many parts of the U.S. resulted in a shift of responsibility for the care of persons with mental illness to their families, who were often ill-equipped to properly care for their relative. In a national survey of families of the National Alliance on Mental Illness, 42% reported living with the relative with mental illness (Skinner et al. 1992). Even when relatives live apart, families often maintain significant contacts and provide great amounts of time, money, and social support to the ill relative (Clark and Drake 1994). Research also has consistently documented the devastating impact of mental illness on families in terms of family/caregiver burden, including feelings of grief, loss, guilt, and anger, feeling drained, worry about the ill relative’s future, economic burden, social isolation, and stigma (Lefley 1996; Marsh 1999; Pejlert 2001; Reinhard 1994; Maurin and Boyd 1990; Saunders 2003). Families also have reported that they have felt blamed rather than helped by professionals (Fisher et al. 1990; Winefield and Burnett 1996). All of these strains resulting from the relative’s mental illness severely tax the family members’ own coping and adjustment and can negatively affect their physical and mental health (Seltzer et al. 1995; Winefield and Harvey 1993). This could be worsened when mental health professionals fail to provide adequate support or information, reject and label the family, or display lack of knowledge (Lefley 1996). Studies have identified a distinct group of services families need to help them cope with caring for their ill relatives. Services include information about the etiology of mental illness and its treatment, practical advice on how to respond to difficult symptoms and situations, emotional support, and information on community resources, respite
123
338
Community Ment Health J (2008) 44:337–345
Methods
phone call to the CSP directors was made to further describe the study and answer questions. Twenty-four of the 25 CSP directors contacted by phone agreed to participate. The majority of CSP directors (n = 21) requested that we mail copies of the questionnaire for them to distribute. These questionnaires included a brief cover letter and stamped, self-addressed envelopes to be returned directly to the researchers. The remaining three directors requested that the researchers meet directly with the staff to explain the study in a group meeting and distribute the questionnaires. After repeated telephone attempts, we were unable to reach five CSP directors. Another letter describing the study and requesting their participation was mailed, along with 20 copies of the survey and stamped, self-addressed envelopes. Four of these five agencies returned surveys. Thus, 28 of 30 CMHCs (93.3%) were represented in the survey, and from these agencies, 521 staff completed and returned the mail questionnaire. The mean number of staff responses per site was 23.2 (SD = 17.5), with a range from 3 to 42. Because the focus of the survey is on mental health professionals’ views of working with families of adults with SMI, staff serving less than five clients with SMI were excluded for the final analyses. Of the final sample (N = 453), the majority were female (73.9%) and Caucasian (88.5%). Most had bachelor’s degree (60.5%) and an additional 27.1% had a graduate degree. On average, they were 39.0 (SD = 11.7) years old (ranging from 22 to 72) and had worked in mental health field for 9.2 (SD = 8.1) years and in their current position for 3.9 (SD = 4.2) years. Psychology (35.2%) and social work (27.4%) were the major disciplines of training. Over two-thirds of the respondents were working as a case manager (55.8%) and team leader/therapist (23.0%), followed by residential program staff, nurse, vocational staff, substance abuse specialist, and psychiatrist. Average caseload size for these respondents was 30.2 and typical number of clients with SMI on their caseload was 28. The study was approved by the Institutional Review Board at Indiana University-Purdue University Indianapolis (IUPUI), the authors have no conflicts of interest to report, and we certify responsibility for the study.
Setting and Study Participants
Measures
Mental health professionals serving adults with severe mental illness (SMI) in Community Support Programs (CSP) providing a range of services such as partial hospitalization, case management, and residential services were recruited to participate in this study. The CSP directors of the 30 Community Mental Health Centers (CMHCs) in Indiana were contacted with an initial letter introducing the survey and asking for their participation. A follow-up
A self-administered staff survey was developed for this study based on previous research (e.g., Dixon et al. 1999, 2000; Greenberg et al. 1995; Kaas et al. 2003; Wright 1997). The first section included background information about the respondent such as gender, age, race, education, area of discipline, current staff position, and length of time in current position. In the second section, respondents reported information on family contact (e.g.,
care, and advocacy (Bernheim and Switalski 1988; Hanson and Rapp 1992; Marshall and Solomon 2000; Smith 2003). Numerous studies have also found that interventions designed to meet the needs of families for information, support, and clinical guidance have positive impacts on both clients and their families. Well-designed clinical family psychoeducation programs have reduced client relapse rates, improved social and vocational functioning, and improved the well-being of the family members, and could enhance the clients’ recovery (Dixon et al. 2001; McFarlane et al. 2000; Penn and Mueser 1996). Moreover, the Schizophrenia Patient Outcome Research Team (PORT) and other recent standards of care have recommended family psychoeducation as part of best practices (Lehman et al. 1998; Weiden et al. 1999). Although some research suggests improvement in provider-family relationships and family satisfaction (e.g., Whelton et al. 1997), there is still evidence suggesting that many family needs go unmet, that families feel disconnected from the treatment process, and that providers often do not reach out to work with families even though families provide a substantial proportion of informal care (Biegel et al. 1995; Greenberg et al. 1995; Jensen 2004; Levine and Ligenza 2002). Explanations for the low use of family interventions in routine mental health practices are relatively limited but may involve barriers at several levels: client and family (e.g., lack of information on family services), mental health professionals (e.g., knowledge & attitudes), and mental health system (e.g., legal and organizational factors, state funding policy) (Bernheim 1990; Dixon et al. 2001; Kaas et al. 2003; Solomon 1994; Wright 1997). The major goals of this study were to examine, from the perspectives of mental health professionals, the extent to which mental health programs provide services to families and to identify barriers to developing such services. Findings from this study could help providers understand how to better address family needs and more actively engage them as collaborators in treatment.
123
Community Ment Health J (2008) 44:337–345
339
frequency, primary contact person) and indicated how often each of 15 types of services were provided in the last six months on a 4-point scale (0 = never to 3 = very often). The third section included eight items to assess staff’s attitudes about working with families. Staff were asked to indicate how much they agree/disagree with each statement on a 5-point scale (1 = strongly disagree to 5 = strongly agree). We conducted factor analyses using principal component analysis with varimax rotation to determine if subscales could be extracted within the service and attitude items. For service items, two factors were identified: one primary factor, accounting for about 48% of the variance and a smaller, second factor that explained an additional 8% of the variance. Because types of services may not form a unidimensional construct, we summed these items to create an index of service provision. Two factors were also extracted from the attitude items, together explaining 48% of variance, but the item spread between these two factors did not produce conceptually meaningful dimensions. Therefore, we summed the items to create an index. Six items were recoded and summed such that higher scores indicated more positive attitudes. Examples of such items included ‘‘Family members often have their own mental health problems’’ and ‘‘Family involvement is often harmful to clients.’’ The last section included 15 items on perceived barriers to implementing family services. Respondents were asked to indicate, on a 4-pont scale (1 = not at all to 4 = great extent) the degree that each item was an obstacle to developing and providing services to families. A factor analysis using principal components analysis with varimax rotation extracted three factors from individual items explaining 46.8% of the variance (See Table 3). The first factor, family/client barrier, consisted of six items, which accounted for 27.8% of the variance (Cronbach’s alpha = .69). The second factor, agency/staff barrier, consisted of six items and accounted for an additional 10.4% of variance (Cronbach’s alpha = .72). The third factor, work-related barrier, consisted of three items and accounted for an additional 8.6% of variance (Cronbach’s alpha = .60). Finally, respondents were asked to report if they have received any training for working with families, and to indicate if they would be interested in training and resources such as in-service training, written materials, or a conference.
training on the amount of service provided, attitudes, and the level of perceived barriers. Two groups of professionals (had ever received training vs. never received training) were compared using t-tests. Because responses were nested within agency, the assumption of independence of observations was checked. The intraclass correlation coefficient [ICC(1)] compares the within-and between-group variances using data generated from oneway analyses of variance (Bliese 2000; Herold et al. 2007; James 1982). A series of ICCs were computed to examine the extent to which group (agency) membership accounted for staff’s response. The low ICCs suggested that responses were independent of each other and did not violate the assumption for t-tests: .052 (Service), .009 (Attitude), .010 (Family/client barrier), .014 (Agency/staff barrier), .027 (Work barrier), .037 (Months in current job), .060 (Number of clients with family contact), .029 (Staff feeling comfortable with their knowledge about effective family treatment), and .007 (Level of family training). Because of multiple t-tests on the same set of data, a modified Bonferroni procedure was used as suggested by Jaccard and Wan (1996). The procedure works by dividing the statistical significance level by the adjusted number of tests and still retains an overall type I error rate of .05.
Data Analysis
Services Provided
Descriptive statistics (e.g., frequency, mean, standard deviation) were used to examine the current level of services provided to families, attitudes, and perceived barriers. We also examined the impact of prior family
As shown in Table 1, more than half of the staff reported that they ‘never’ or ‘not very often’ provided 9 out of 15 services in the last six months to families of adults with SMI on their caseload. The mean scores of
Results Report of Family Contact Staff reported that for about a third of clients on their caseload, they had at least one contact with clients’ family members during the past six months. Even among those families with whom they had contact, such contact occurred relatively infrequently. About 49.9% reported that they had contact with a family member ‘‘a few’’ times during the past six months and 15.6% said that they had only a single contact with a family member during this time period. Not surprisingly, staff were most likely to have contact with the client’s mother (51.5%), followed by sibling (13.2%), and spouse (7.8%). Contacting families via phone (68.5%) was the most common form of contact and the majority of contacts (88.2%) lasted less than 30 minutes. About 47.1% of staff reported that they initiated the contact.
123
340
Community Ment Health J (2008) 44:337–345
Table 1 Types of services provided to families in the last 6 months (N = 453) Types of services
Mean (SD)
Never N
Provided emotional support
2.14 (0.9)
25
% 6.0
Not very often/sometimes
Very often
N
%
N
%
215
51.2
180
42.9
Provided practical advice about how to cope with specific situations
2.03 (0.9)
37
8.8
227
53.8
158
37.4
Provided information about the client’s illness and treatment (including medications) Informed families of the client’s progress
1.89 (0.9)
33
7.8
277
65.3
114
26.9
1.87 (0.9)
40
9.6
264
63.5
112
26.9
Discussed future plans for client with family
1.78 (0.9)
39
9.2
286
67.8
97
23.0
Provided orientation to services
1.52 (1.0)
79
18.7
271
64.1
73
17.3
Included family in the client’s treatment planning
1.33 (0.9)
86
20.4
291
69.1
44
10.5
Advocated for needed services
1.33 (1.0)
105
25.0
257
61.2
58
13.8
Provided families with crisis intervention services
1.31 (1.0)
122
28.9
245
58.1
55
13.0
Taught identification of early warning signs of relapse
1.29 (0.9)
105
24.9
277
65.6
40
9.5
Mediated conflicts between families and the client
1.28 (0.9)
108
25.7
263
62.6
49
11.7
Referred families to support groups (e.g., NAMI)
1.18 (1.0)
129
30.7
241
57.4
50
11.9
Taught methods for monitoring medications
1.14 (1.0)
139
33.3
234
55.9
45
10.8
Taught stress management strategies
1.14 (1.0)
144
34.0
226
53.4
53
12.5
Provided family therapy to the family
0.42 (0.7)
298
71.1
111
26.5
10
2.4
Notes: Types of services were rated on a 4-point scale (0 = never, 1 = not very often, 2 = sometimes, 3 = very often). Due to missing data, Ns for individual items range from 416 to 424
service items ranged from 0.42 to 2.14 (where the scale ranges from 0 = never, 1 = not very often, 2 = sometimes, 3 = very often), which indicated that the overall level of services mental health professionals provided to families was quite low. The most frequently reported types of services (percentage responding ‘‘very often’’) were providing emotional support (42.9%), practical advice about coping with specific situations (37.4%), and information on mental illness (26.9%), informing family of the client’s progress (26.9%), and discussing future plans for the client (23.0%). The least frequently reported services were providing family therapy (2.4%), teaching identification of early warning signs of relapse (9.5%), including family in client’s treatment planning (10.5%), teaching methods for medication monitoring (10.8%), and referring family to support group (11.9%). The majority of the staff believed that overall families were somewhat (53.3%) or very satisfied (30.7%) with the services they received. Mental Health Professionals’ Attitudes As shown in Table 2, though many did not view family involvement as harmful to clients and saw families as being cooperative, over 60% of respondents reported that families often have their own mental health problems and unrealistic expectations about client’s progress. Only 36.5% believed that many families have learned to manage the client’s illness over time.
123
Barriers to Implementing Services for Families Responses to individual items are shown in Table 3. Four of the six most frequently reported barriers (at least a moderate extent) were family/client barrier factor. Over 60% of staff identified lack of involvement/interest from families, financial burden to families, client’s refusal to involve family, and family’s lack of knowledge about mental illness as moderate/great barriers. Two other items from work-related barrier factor, having too many demands (65.3%) and inability to provide services on evenings and weekends (68.4%) were also reported by a large percentage of respondents. However, the majority of staff did not view agency/staff variables such as agency structure, regulation or staff themselves as major barriers. For example, over 60% reported that lack of support or guidance from the agency, confidentiality, lack of competency among staff, and lack of cultural competency were not at all or only minor barriers. An open-ended question was also asked to solicit additional comments on providers’ views about other barriers. Consistent with what providers reported in Table 3, client/ family related barriers were most frequently reported. Of 204 who responded to this question, 39.7% reported that family’s lack of involvement due to various reasons such as lack of interest, burn out, lack of knowledge about mental illness, and having their own mental health issues is one of the major barriers to working with families. Family’s lack of time (13.2%), funding (12.3%), and staff’s time
Community Ment Health J (2008) 44:337–345
341
Table 2 Mental health professionals’ attitudes (N = 453) Attitudes
Mean (SD)
Strongly disagree/ disagree
Neutral
N
%
N
Strongly agree/ agree %
N
%
Family members often have their own mental health problems
3.65 (0.9)
49
10.9
102
22.7
299
66.4
Families often have an unrealistic expectation for client’s improvement
3.60 (0.9)
63
13.9
99
21.9
290
64.2
Families are cooperative
3.37 (0.8)
67
14.8
158
35.0
227
50.3
Family has little knowledge about mental illness
3.23 (1.1)
150
33.2
70
15.5
232
51.3
Many families have learned to manage the client’s illness
3.02 (0.9)
154
34.1
133
29.4
165
36.5
Families have difficulty communicating with staff
2.95 (0.9)
167
37.3
134
30.0
146
32.7
Families are often resistant to staff’s suggestions
2.77 (0.9)
200
44.3
149
33.0
103
22.8
Family involvement is often harmful to clients
2.27 (0.9)
293
64.8
118
26.1
41
9.0
Notes: Professionals’ attitudes were rated on a 5-point scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Due to missing data, Ns for individual items range from 447 to 452
constraints (12.3%) are other frequently reported barriers. Only 6.9% mentioned problems with providers themselves (e.g., negative attitude, lack of willingness or qualification to work with families) as an additional barrier. Training Needs of Mental Health Professionals Only 38% (N = 168) reported that they had ever received training about working with families of adults with SMI, and only 17.8% (N = 78) reported that their agency offered a training on this topic in the past year. The most
frequently reported types of training included in-services and workshops, which emphasized the importance of including families and addressing their needs. Very few staff reported that they had received more structured family psychoeducation training. As shown in Table 4, when the two groups of respondents were compared, on average, respondents who had ever received training had significantly more contacts with families, provided more services to families, had more positive attitudes toward working with family, and felt more comfortable with their knowledge of working with families than staff who had
Table 3 Barriers to implementing services for families (N = 453) Factor loading Mean (SD) Not at all/minor N
%
Moderate
Great
N
N
%
%
Factor 1: Family/client barriers Lack of involvement/interest from families
0.72
2.89 (0.8)
136
30.7
195 44.0 112 25.3
Family’s lack of knowledge about client’s mental illness
0.60
2.84 (0.7)
139
31.3
228 51.4
Financial burden to families
0.48
2.76 (0.9)
164
37.2
173 39.2 104 23.6
Client’s refusal to involve families
0.52
2.75 (0.8)
178
40.1
189 42.6
77 17.3
Family’s difficulty communicating with staff Geographic limitations
0.67 0.55
2.43 (0.8) 2.39 (0.9)
242 253
54.8 57.2
167 37.8 135 30.5
33 7.5 54 12.2
Complex nature of working with families
0.41
2.49 (0.7)
230
51.8
177 39.9
37
8.3
Lack of guidance and leadership from the agency
0.70
2.28 (0.9)
256
58.2
149 33.9
35
8.0
Confidentiality
0.47
2.27 (1.1)
273
61.6
83 18.7
77 17.3
Factor 2: Agency/staff barriers
87 19.6
Lack of competency among staff
0.69
2.11 (0.8)
294
66.7
129 29.3
18
4.1
Lack of cultural competency
0.50
2.07 (0.8)
330
74.7
90 20.4
22
5.0
Skepticism about added value of family interventions
0.68
1.99 (0.8)
336
75.8
88 19.9
19
4.3
Factor 3: Work-related barriers Inability to provide services to families on evenings and weekends 0.78
2.86 (0.9)
139
31.6
182 41.4 119 27.0
Already too many demands on staff
0.69
2.80 (0.8)
154
34.7
195 43.9
95 21.4
Lack of support from the agency
0.57
2.09 (0.9)
305
69.5
100 22.8
34
7.7
Notes: Barriers were rated on a 4-point scale (1 = not at all, 2 = minor, 3 = moderate extent, 4 = great extent). Due to missing data, Ns for individual items range from 439 to 444
123
342
Community Ment Health J (2008) 44:337–345
Table 4 Comparison of staff who have received versus have not received training Ever received training (N = 168) Mean (SD)
Never received training (N = 256) Mean (SD)
Number of months in current position
56.66 (63.7)
41.12 (39.3)
2.83**
0.31
Number of clients with family contacta
12.32 (14.0)
7.08 (6.4)
4.45***
0.52
3.72 (0.8)
3.23 (0.9)
5.67***
0.57
Services provision indexb
24.84 (9.3)
19.23 (9.0)
6.01***
0.61
Staff’s attitude indexc
24.53 (4.2)
23.39 (4.1)
2.75**
2.65 (0.5)
2.70 (0.5)
Staff feeling comfortable with their knowledge of effective treatment for families
Family/client barrier factord (Mean score)
t Value
-0.87
Effect size
0.27 -0.08
Agency/staff barrier factord (Mean score)
2.16 (0.5)
2.24 (0.6)
-1.50
-0.16
Work-related barrier factord (Mean score)
2.53 (0.6)
2.64 (0.7)
-1.68*
-0.17
Note: * P \ .10; ** P \ .01; *** P \ .001 a
Number of clients for whom provider contacted family (at least once in the last 6 months)
b
Summary score of 15 service items on a 4-point scale (0 = never to 3 = very often)
c
Summary score of 8 items; Negative items were recoded to indicate higher scores representing more positive attitudes on a 5-point scale
d
Barriers were rated on a 4-point scale (1 = not at all to 4 = great extent)
never received training. Most of these group differences were within the range of small and medium effects (Cohen 1988). There were no statistically significant group differences in regards to the three barrier factors though perceived work-related factor approached significance. When asked about the training/resources of interest, the majority indicated strong interest in receiving in-service training (89.2%) or written materials (85.8%), and attending a day-long conference (74.8%). In an open-ended question, they also indicated that they would like to have more ongoing training as a part of continuing education, receive video tapes or training manuals specifically describing issues and steps to work with families, attend guest speaker’s presentations, receive resource manuals/ lists as well as emails on any upcoming trainings/conferences in this area. Relationships Between Attitudes, Barriers, Training and Services We examined the bi-variate correlations between study variables to examine the degree of interrelatedness. As shown in Table 5, the relationships between variables were of small to medium effect (Cohen 1988). The service provision index was most closely related to number of clients with family contact, comfort level with providers’ knowledge about family services, and prior training. Although attitudes were not related to the amount of services provided, they were significantly related to perceived barriers to working with families and prior training.
123
Discussion The mental health professionals in this study had limited contacts with families and did not frequently provide a wide range of services to families, consistent with previous studies (Biegel et al. 1995; Marshall and Solomon 2004; Rose 1998). The most frequently reported services were emotional support and practical advice about how to cope with specific situations. However, few provided family therapy, taught identification of early warning signs of relapse, included family in client’s treatment, or referred family to support groups. Many respondents believed that education and emotional support were the most important needs for family which are consistent with previous studies reporting families’ needs (Dixon et al. 2001). However, the overall level of services provided to families in the last six months was quite low. It is also worth noting that the majority of staff believed that families were satisfied with the services they had received. Future research should examine whether families share the same perspectives of services they had received in terms of the level, type, and satisfaction. It also should be noted that although these are low levels of services, we cannot determine from this data the appropriateness of this level of care. For example, the survey did not include indicators of clients’ length of time in treatment, functioning, and clinical status in the last six months, which may affect both family involvement and the need for and types of family services provided. Lack of such information on clients may make it difficult to evaluate from the finding whether mental health providers are adequately responding to the needs of families. Some
Community Ment Health J (2008) 44:337–345
343
Table 5 Correlations between study variables Variable
Variable 1
(1) Number of months in current job
2
3
5
6
7
8
0.16**
1.00
(3) Staff feeling comfortable about knowledge of family treatment (4) Service providedb
0.07
0.25**
-0.03 0.01
0.34** -0.02
1.00 0.26**
1.00
0.10*
0.04
1.00
d
-0.03
0.03
0.05
-0.32**
(7) Agency/staff barrierd
0.03
-0.01
-0.23**
-0.02
-0.13**
0.51**
1.00
(8) Work-related barrierd
0.12
0.03
-0.18**
-0.02
-0.14**
0.30**
0.41**
(9) Ever received family training
0.09*
0.21**
(6) Family/client barrier
9
1.00
(2) Number of clients with family contacta
(5) Staff attitudec
4
-0.08
0.21**
0.28**
0.13**
1.00
-0.03
-0.07
1.00 -0.06
1.00
Note: * P \ .05; ** P \ .01 a
Number of clients for whom provider contacted family (at least once in the last 6 months)
b
Summary score of 15 service items on a 4-point scale (0 = never to 3 = very often)
c
Summary score of 8 items; Negative items were recoded to indicate higher scores representing more positive attitudes on a 5-point scale
d
Barriers were rated on a 4-point scale (1 = not at all to 4 = great extent)
services (e.g., mediating conflict, crisis intervention) may be episodic and not be needed during the particular sixmonth period we assessed. However, other services may be expected to occur more commonly across time, such as being included in the treatment process or being informed about their relative’s progress and these areas were also infrequently reported services. Thus, it still appears that providers need to pay more attention to families’ ongoing need for services. There were mixed findings about mental health professionals’ attitudes toward families. The majority of staff reported perceived benefits of family interventions. However, many providers still strongly endorsed items implying negative attitudes toward family. Similarly, in an openended question about barriers, several respondents specifically mentioned that families often had negative impacts on clients’ progress and they needed to be separated from clients. Contrary to the earlier research (Marshall et al. 2003), this negative attitude was not related to amount of service or number of clients with family contacted. However, many mental health professionals viewed barriers to collaboration as stemming from the clients or families such as lack of family interest, lack of family knowledge about mental illness, financial burden, and client’s refusal to involve families. In addition, the literature recognizes stigma, burnout, and the cost of mental health care as significant factors limiting families’ involvement in the care of clients (Karanci 1995; Solomon 1994). The professionals included in this survey did not view variables related to themselves (e.g., competency, attitudes) nor lack of support and guidance from the agency as major barriers. However, other research has shown that
mental health professionals’ attitudes serve as a major barrier to developing collaborative relationships with families (Kaas et al. 2003; Winefield and Burnett 1996). Staff training and education could overcome this barrier by changing staff attitudes and improving their understanding of families’ needs as well as their skills for working with families (Craig et al. 1999; Kaas et al. 2003). Consistent with previous research (Mohr 2000), few mental health professionals reported that they were trained to work effectively with families as a collaborator and only half of respondents reported that they felt comfortable with their knowledge and skills about how to work with families. However, respondents with previous training provided more services to families, had more positive attitudes toward working with families, and felt more competent about their skills and knowledge than those who had never received training. In addition, the majority of respondents wanted to receive more ongoing training. These findings suggest a strong need for more staff training in working with families. It is also strongly recommended that the staff training focus on helping providers develop a partnership with clients and families who may have different levels of interest in family involvement. For example, in one study, clients reported the lack of inclusion of friends and families in treatment planning as one of their major unmet needs, while others found that about a third of clients did not want family involvement (Eisen et al. 2002; Howard et al. 2003). Previous studies suggest that the challenges of different levels of interest in family involvement may be addressed by several strategies. Developing clear policy guidelines and a specific form for release of information to
123
344
share treatment information can facilitate family involvement and partnership (Bogart and Solomon 1999). Helping families get educated about mental illness and learn more effective ways to communicate with their relatives will improve relationships between family members and clients, which will influence their interest in family involvement (Williams and Mfoafo-M’Carthy 2006). Also having ongoing dialogue with clients about family involvement can change their attitudes and willingness to include their family in the treatment process (Marshall and Solomon 2000). This study included a relatively large sample of respondents, validated the findings of prior research with regard to mental health professionals’ attitudes and perceived barriers, and shed some light on needs for future training. However, there are limitations to the generalizability of these findings. Even though we had overall good response rates, not all staff chose to participate in the study. The study also did not use random sampling, and it is not known how this self-selected sample would be representative of all the mental health professionals working with adults with SMI. The survey questions were developed for this study based on previous research but may not capture other important information to measure level of services provided, staff attitudes, and perceived barriers (e.g., client level of functioning as described above). Another important limitation of this study is that these findings represent only providers’ perspectives. To get a more complete picture, family perspectives should be examined and compared. In conclusion, given the serious nature of SMI, its impact on the family, and the responsibility for care that families continue to shoulder, creating alliances between mental health professionals and families is no longer optional. Moreover, assisting families to carry out caregiving functions would in turn enhance the recovery process of clients. Thus, there is good justification for directing our attention to the needs of these families and development of more effective service systems to address their needs. Acknowledgments This project was supported by a grant from the Indiana Division of Mental Health and Addiction. We thank Hollie MacKay, Dawn Shimp, and Joy Piland for their help with this project.
References Bernheim, K. (1990). Principles of professional and family collaboration. Hospital and Community Psychiatry, 41(12), 1353– 1355. Bernheim, K., & Switalski, T. (1988). Mental health staff and patient’s relatives: How they view each other. Hospital and Community Psychiatry, 39, 63–68. Biegel, D. E., Song, L., & Milligan, S. (1995). A comparative analysis of family caregivers’ perceived relationships with mental health professionals. Psychiatric Services, 46(5), 477–482.
123
Community Ment Health J (2008) 44:337–345 Bliese, P. D. (2000). Within-group agreement, non-independence, and reliability: Implications for data aggregation and analysis. In K. J. Klein & S. W. Kozlowski (Eds.), Multilevel theory, research, and methods in organization (pp. 349–381). San Francisco, CA: Jossey-Bass, Inc. Bogart, T., & Solomon, P. (1999). Procedures to share treatment information among mental health providers, consumers, and families. Psychiatric Services, 50(10), 1321–1325. Clark, R., & Drake, R. (1994). Expenditures of time and money of families of people with severe mental illness and substance abuse disorders. Community Mental Health Journal, 30, 145–163. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Craig, T., Guy, S., & Ogilvie, L. (1999). An evaluation of a practitioner training program designed to assist families of people with severe psychiatric disorders. Psychiatric Rehabilitation Journal, 23(1), 34–42. Dixon, L., McFarlane, W. R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I., Mueser, K. T., Miklowitz, D., Solomon, P., & Sondheimer, D. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52(7), 903–910. Dixon, L., Lucksted, A., Stewart, B., & Delahanty, J. (2000). Therapists’ contacts with family members of persons with severe mental illness in a community treatment program. Psychiatric Services, 51(11), 1449–1451. Dixon, L., Lyles, A., Scott, J., Lehman, A., Postrado, L., Goldman, H., & McGlynn, E. (1999). Services to families of adults with schizophrenia: From treatment recommendations to dissemination. Psychiatric Services, 50(2), 233–238. Eisen, S. V., Wilcox, M., Idiculla, T., Speredelozzi, A., & Dickey, B. (2002). Assessing consumer perceptions of inpatient psychiatric treatment: The perceptions of care survey. The Joint Commission Journal on Quality Improvement, 28(9), 510–526. Fisher, G., Benson, P., & Tessler, R. (1990). Family response to mental illness: Developments since deinstitutionalization. In J. R. Greenley (Ed.), Research in community and mental health: Mental disorder in social context (pp. 273–294). Greenwich, CT: JAI. Greenberg, J., Greenley, J., & Kim, H. (1995). The provision of mental health services to families of persons with serious mental illness. In J. Greenley (Ed.), Research in community and mental health (Vol. 8, pp. 181–204). Greenwich, CT: JAI Press. Hanson, J., & Rapp, C. (1992). Families’ perceptions of community mental health programs for their relatives with a severe mental illness. Community Mental Health Journal, 28, 181–197. Herold, D., Fedor, D., & Caldwell, S. (2007). Beyond change management: A multilevel investigation of contextual and personal influences on employees’ commitment to change. Journal of Applied Psychology, 92(4), 942–951. Howard, P. B., El-Mallakh, P., Rayens, M. K., & Clark, J. J. (2003). Consumer perspectives on quality of inpatient mental health services. Archives of Psychiatric Nursing, 17(5), 205–217. Jaccard, J., & Wan, C. K. (1996). LISREL approaches to interaction effects in multiple regression. Thousand Oaks, CA: Sage Publication. James, L. R. (1982). Aggregation bias in estimates of perceptual agreement. Journal of Applied Psychology, 67(2), 219–229. Jensen, L. (2004). Mental health care experiences: Listening to families. Journal of the American Psychiatric Nurses Association, 10(1), 33–41. Kaas, M., Lee, S., & Peitzman, C. (2003). Barriers to collaboration between mental health professionals and families in the care of persons with serious mental illness. Issues in Mental Health Nursing, 24, 741–756.
Community Ment Health J (2008) 44:337–345 Karanci, A. (1995). Caregivers of Turkish schizophrenic patients: Causal attributions, burdens, and attitudes to help from the health professionals. Social Psychiatry and Psychiatric Epidemiology, 30, 261–268. Lefley, H. P. (1996). Family caregiving in mental illness. Family caregiver application series (Vol. 7). Sage Publications. Lehman, A. F., Steinwachs, D. M., & PORT Co-Investigators. (1998). At issue: Translating research into practice: The Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin, 24, 1–10. Levine, I., & Ligenza, L. (2002). In their own voices: Families in crisis: A focus group study of families of persons with serious mental illness. Journal of Psychiatric Practice, 8, 344–353. Marsh, D. (1999). Serious mental illness: Opportunities for family practitioners. The Family Journal: Counseling and Therapy for Couples and Families, 7(4), 358–366. Marshall, T. B., & Solomon, P. (2000). Releasing information to families of persons with severe mental illness: A survey of NAMI members. Psychiatric Services, 51(8), 1006–1011. Marshall, T. B., & Solomon, P. (2004). Provider contact with families of adults with severe mental illness: Taking a closer look. Family Process, 43(2), 209–216. Marshall, T. B., Solomon, P., Steber, S., & Mannion, E. (2003). Provider and family beliefs regarding the causes of severe mental illness. Psychiatric Quarterly, 74(3), 223–236. Maurin, J. T., & Boyd, C. B. (1990). Burden of mental illness on the family: A critical review. Archives of Psychiatric Nursing, 4(2), 99–107. McFarlane, W. R., Dushay, R. A., Deakins, S., Stastny, P., Lukens, E., Toran, J., Link, B. (2000). Employment outcomes in familyaided assertive community treatment. American Journal of Orthopsychiatry, 70, 203–214. Mohr, W. (2000). Rethinking professional attitudes in mental health settings. Qualitative Health Research, 10, 595–611. Pejlert, A. (2001). Being a parent of an adult son or daughter with severe mental illness receiving professional care: Parents’ narratives. Health and Social Care in the Community, 9(4), 194–204. Penn, D., & Mueser, K. (1996). Research update on the psychosocial treatment of schizophrenia. American Journal of Psychiatry, 153, 607–617.
345 Reinhard, S. C. (1994). Living with mental illness: Effects of professional support and personal control on caregiver burden. Research in Nursing and Health, 17, 79–88. Rose, L. (1998). Benefits and limitations of professional-family interactions: The family perspective. Archives of Psychiatric Nursing, 12(3), 140–147. Saunders, J. (2003). Families living with severe mental illness: A literature review. Issues in Mental Health and Nursing, 24, 1 75–198. Seltzer, M., Greenberg, J., & Krauss, M. (1995). A comparison of coping strategies of aging mothers of adults with mental illness or mental retardation. Psychology and Aging, 10(1), 64–75. Skinner, E., Steinwachs, D., & Kasper, J. (1992). Family perspectives on the service needs of people with serious and persistent mental illness. Innovations & Research, 1, 23–30. Smith, G. (2003). Patterns and predictors of service use and unmet needs among aging families of adults with severe mental illness. Psychiatric Services, 54(6), 871–877. Solomon, P. (1994). Families’ views of service delivery: An empirical assessment. In H. P. Lefley & M. Wasow (Eds.), Helping families cope with mental illness (pp. 259–274). Newark, NJ: Harwood Academic. Weiden, P., Scheifler, P., McEvoy, J., et al. (1999). Expert consensus treatment guidelines for schizophrenia: A guide for patients and families. Journal of Clinical Psychiatry, 60(suppl 11), 73–80. Whelton, C., Pawlick, J., & Cardamone, J. (1997). Involving families in psychological rehabilitation. Psychiatric Rehabilitation Journal, 20, 57–60. Williams, C. C., & Mfoafo-M’Carthy, M. (2006). Care: Giving, receiving and meaning in the context of mental illness. Psychiatry, 69(1), 26–46. Winefield, H., & Burnett, P. (1996). Barriers to an alliance between family and professional caregivers in chronic schizophrenia. Journal of Mental Health, 5(3), 223–233. Winefield, H., & Harvey, E. (1993). Determinants of psychological distress in relatives of people with chronic schizophrenia. Schizophrenia Bulletin, 19, 619–635. Wright, E. (1997). The impact of organizational factors on mental health professionals’ involvement with families. Psychiatric Services, 48(7), 921–927.
123
