Review of the concept ‘Family Focused Care’ Burden’ when caring for people with mental health problems



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Review of the concept ‘Family Focused Care’ Burden’ when caring for people with mental health problems.

Introduction
According to Houlihan et al (2013), there is a growing expectation that mental health practitioners work in more family focused ways by providing support to children, parents and other family members. Family focused care considers fostering improvement of mental health and wellbeing for children of parents with a mental health problem, their parents and families (O’Brien et al., 2011). Foster et al. (2012:7) define family focused care as:
A method of care delivery that recognises and respects the pivotal role of the family. The key element of family focused care is a philosophy of care, incorporated into practice, which recognises the uniqueness of each consumer and family.
This concept emerged in response to a range of papers that described strategies that assist mental health nurses to work in more family focused ways or papers that help mental health nurses to understand the family, the concept of family focused care and interventions to improve the provision of care to families. Central to understanding the concept of family focused care is a consideration of the concept of the ‘family’. While the family cannot be described in heterogeneous terms, there is a tendency to make assumptions about the nature and constitution of the family. In order to understand the needs of the family, mental health nurses need to consider the composition and relationships within each family that they interact with (Weber, 2010). While the broad professional values associated with mental health nurses are enough to encompass interventions with all families, mental health nurses need to consider that non-traditional or alternate families exist and may need specific interventions tailored to meet their needs. In addition, mental health nurses need to be non-judgmental in their encounters with families that do not fit within traditional interpretations of the family (Weber, 2008). This includes being aware of sensitive to families cultural needs (Hultsjo et al, 2007).
From a family and carer perspective, family-focused care means that the subjective experience of illness is valued and the family have an opportunity to share the illness narrative with professionals and that they are helped to maintain hope (Tweedell et al., 2004; Hultsjo et al., 2007). Central to this is the development of a good relationship with families and positive attitudes towards them. Establishing a good relationship with the family and carers fosters a sense of security for them and improves their esteem and general quality of life. Carers and family members have different expectations about the care that their loved one receive and also about how they want to be treated themselves. Family involvement in general is seen as very important and families expect support, respectful behaviour, engagement and an interest in their experiences and needs. They expect the possibility of discussing their worries and also speedy action from professionals when they are asking for help. Mental health problems are changing things in the family and therefore they need to be helped to “make a place for schizophrenia in the redefinition of the self which does not negate their experience of living alongside the mental illness”.
Care can be experienced as a meaningful, trusting relationship between the family, service user and professional. It can include reciprocal honesty and openness, a sense of wholeness and autonomy facilitated by a versatile interchange of knowledge and understanding (Piippo & Aaltonen, 2008). The meaning of mental illness is negotiated in the family and the family could be seen as mediating context where this meaning is created (Tweedell et al., 2004). Within the family, the meaning of mental illness has a constructed nature in this sense. As family is a part of the larger society, it is also affected by “larger cultural discourse or set of meanings and beliefs about vulnerability and depending” (Boschma, 2007). To understand the meaning of mental illness to family the “meaning of their stories about illness should be interpreted carefully by continuously linking individual experiences to larger, changing historical context” (Boschma, 2007).
Mental health nurses need to work to empower carers and families and empowerment can be seen as means to create a context or environment, to do counselling and engaging participants in development (Gavois et al,, 2006) (13). It’s important to support family members’ participation and involvement in care as it enables the sharing of information and the use of families’ own resources and skills (Reed, 2008). Motivational interviews could be considered as one technique to use when trying to get families’ to recognise their own strengths (Mahone et al., 2011). Empowering way of working includes “acknowledging the experience and knowledge that service user and family have and the skills that have been developed to cope with impact of symptoms in everyday life” (Maskill, 2010).

There are ethical dilemmas when working with families and this includes dilemmas about the sharing of information. This may put pressure on relationships within the family in terms of respecting the rights of service user to confidentiality while also respecting the rights of family caregivers to information that directly affects them (Rowe, 2010). There might also be contradictions between family members and professionals (Rowe, 2010; Small et al., 2010) and families’ can feel that their concerns are not overridden by professionals or that professionals lack understanding (Rowe, 2010). In addition, family’s and patient’s perceptions on mental health and illness,(e.g schizophrenia), might differ from the perception of professionals. For the family members the route from onset of symptoms and acute phase towards more stable condition could be describes as moving from “crisis to recovery” (Gavois et al., 2006). Collaboration between the patient, family and nurse is needed, but also collaboration between professionals (Hultsjo et al., 2007; Maskill et al., 2010). Collaboration demands high-quality interaction skills and different skills and their purposes have been described in the literature. Everything starts with the skills to be present with patient and family which includes early contact, early information and protection (Gavois et al., 2006). Listening is important, with listening, burden could be assessed and contact could be maintained (Gavois et al., 2006). Listening should be active listening and in his/her own interaction the nurse should be aware of the language that they use; person-centred, person-first language should be used (Mahone et al., 2011). Interaction enables sharing with patient and family members; this provides open communication, security, and negotiation. Foster et al. (2012) describe a framework for family focused care for children and families with parental mental illness.


The need for information and knowledge is very high in the family, especially if they are facing mental health problems for the first time. Even if there are previous experiences, level of information might be low or there can be misunderstandings or lack of information. However appropriate information is needed to help family member’s to understand the mental health problems and their impact on the everyday life of the patient and for themselves. Also information about what services are available and how these could be accessed should be provided to family members (Tweedal et al., 2004; Sin et al., 2007). The educational needs of family and patients may differ from their needs as perceived by mental health professionals (Sung et al., 2004). When patients are being discharged from hospital it is important that the family who are caring for the individual are educated about preventative and carung approaches that could be used when the patient gets home (Sunget al., 2004; Sun et al., 2007; Marshall & Harper -Jaques). In addition, knowledge of the risks that children face and preventative strategies need to be included in education programmes for nurses (Korhonen et al., 2010; Houlihan et al., 2013).

Young people who are carers feel that they are being excluded from decisions relating to themselves and those they were caring for. In addition they feel that they are often dismissed by professionals as unimportant, and indirectly excluded through the use of ‘professional’ and/or adult language. Young carers describe themselves as ‘the forgotten’. This corresponds with O’Brien et al (2011) and Houlihan et al (2013) who describe children of people with mental health problems as ‘invisible’ or ‘hidden’. The young person needs to feel respect from the healthcare staff and the organizations and they ask for opportunities for genuine participation in the patients care and in this way feel involved.


There are some specific barriers to family focused care. O’Brien et al (2011) suggest that there are no specific guidelines to working with the children of people with mental health problems and that staff felt ill equipped to relate to children about mental health and illness. Nurses who received specifically designed education and training about working with families viewed families in a more positive light and found families less burdensome (Sveinbjarnardottir et al., 2011). Central to this is the adoption of an advocacy role which can activate social and professional supports while ensuring that the unique needs of the individuals are maintained and their rights upheld (Lagan et al., 2009). According to Korhonen et al (2008), family related barriers such as lack of time and families fears were the most hindering factors when implementing child focused family nursing.



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