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Centering the Family: What It Means to Implement Family-Focused Practice (FFP) in Adult Mental Health Care

Providers have an important role and responsibility to engage families when patients have a psychiatric hospitalization. HIPAA is often used to deny patients’ families access to critical information. By educating and engaging families along the way, we can significantly reduce patient readmission and improve after-care.

Portrait of happy young black family with little kids sitting on the couch smiling

In partnership with Manhattan Together, NAMI-NYC surveyed patients who have had a psychiatric ER visit in NYC. The ER experience improved when patients were able to stay with their families. With their families, patients found hospital staff provided them with support and that they were treated with dignity. When families are excluded during hospitalization, patients not only had a worse experience, but hospital staff are functioning without critical family knowledge. Our survey found that families often wanted to give hospital medical staff information about the patient’s situation at home but were not allowed to do so during admission.

Family members have patient history and “real time” observations that practitioners do not have access to.[i] Families would also be aware of Psychiatric Advance Directives (PAD), which is a legal document outlining a person’s preferences for future mental health treatment and names an individual to make decisions when the patient is in crisis.[ii] PADs are highly underutilized in clinical settings even though such documents can prevent coercive crisis interventions.

This recent psych ER survey and stories from our community tell us that we need to center the family in adult mental health services. Family-Focused Practice (FFP) is a “whole family” approach to care, including family care planning and goals, a family and service liaison, individual and family focused support, individual and family-focused assessment, psychoeducation, and a coordinated system between families and services.ii It also emphasizes the relational aspect of the recovery journey, as well as acknowledges intergenerational mental health needs.iii

A study of 200 inpatients with serious mental illness at New York hospitals in 2019 found that family involvement was beneficial.[iii] Family involvement was defined as at least one interaction between family and inpatient staff, including discussion of services available to the family, the patient’s health or mental health, discharge date, post discharge treatment plan, post discharge residence, warning signs of decompensation, ways to prevent readmission, or concerns about discharge or treatment. When there were family phone calls or visits, attendance at family therapy sessions, and communication with staff, patients were more likely to receive comprehensive discharge planning. Family engagement was also significantly associated with entry into follow-up care within 7 to 30 days of discharge, and adherence to post discharge medication.

The pandemic provided lessons on how to communicate with families too. One NYC study offers best practices for working with families, as well as supporting them.i The hospital teams – the palliative care and psychiatric departments — created a new remote liaison role for psychiatric residents. When receiving the case, the resident would call the family to explain their role and call to follow up 2-3 times weekly. The psychiatric residents provided supportive counseling to the family, normalized their grief and anxiety, listened to their fears and hopes, as well as learned more about the patient. The residents also shared healthy coping mechanisms with families and connected them to social benefits and programs from food and unemployment to mental health services. Interpretation services were available, and all calls were documented in the patient’s chart. The hospital also offered post-hospitalization care for families.

There is still a great deal of uncertainty around how FFP is implemented. Family-Focused Practice is more often implemented when a child is involved, but can be incredibly effective in adult mental health services, as well.vi Practitioners play a key role as an intermediary among service providers, families, and organizations, but often find that they don’t have the adequate resources to prioritize the practice.iv There’s often a lack in confidence, skills, and knowledge in the real-world practice of FFP.

Not enough government and organizational policies authorize and promote family-focused practices either. vii Innovative approaches include the Effective Family Program in Finland, the Think Family initiative in the U.K., Children of Parents with a Mental Illness and Families where a Parent Has a Mental Illness in Australia.[iv] In Scandanavia, legal amendments have been passed requiring practitioners in adult mental health services to identify and assist with needs of children whose parents are using services.[v]

If you’re a provider looking to implement FFP in adult mental health services, research recommends six action points:[vi]

  1. Health care providers must identify practitioner and family readiness for the “therapeutic alliance.” Readiness is just as important on both sides.
  2. Practitioners need both the flexibility to implement as well as monitor their own family focused practice. They need to understand how patient mental illness impacts family members, and practice how to hold a dual perspective.
  3. FFP must be a part of an organization’s identity and built into policy. FFP will be a part of core competencies recruitment, as well as practitioner training, support, and monitoring systems. Outcome measures will include family well-being.
  4. Leadership at various levels of the organization must support FFP, including communicating family-focused practice as a priority, developing training, and creating reporting systems. Managers will facilitate family-inclusive mental health practice in daily work.
  5. An internal implementer can ensure sustainability. The implementer can support leadership and build practitioners’ skills and confidence.
  6. Both the implementation and practice of FFP can transform larger funding and political context of the organization. If the provider measures parent, children, and family outcomes, the lens will shift from individuals to family resilience and wellbeing.

Family-Focused Practice demonstrates that “family matters” and can have positive, long-lasting impact on individuals living with serious mental illness.v We hope that our healthcare leaders will make families a priority in mental health care – for the wellbeing of patients, families, and our communities.

Matt Kudish is the CEO of the National Alliance on Mental Illness of New York City (NAMI-NYC), which has centered families and individuals affected by mental illness and their families for 40 years. Learn more about our family classes, support groups, mentoring, Helpline, and more at www.naminyc.org.

Sources

Allchin, B., Weimand, B., O’Hanlon, B. (January 2022). A Sustainability Model for Family-Focused Practice in Adult Mental Health Services. Frontiers in Psychology. https://www.researchgate.net/publication/357912097_A_Sustainability_Model_for_Family-Focused_Practice_in_Adult_Mental_Health_Services

Bauer, A., Best, S., Malley, J. et. al. (October 2021). Toward a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview with Program Leaders. Frontiers in Psychology. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.741225/full

Family Participation: Make the Mental Health System Work for You. NYS OMH.

https://omh.ny.gov/omhweb/consumer_affairs/resources/docs/make_mh_syswork.pdf

Haselden, M., Corbeil, T., Tang, F., et. Al. (July 2019). Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Prompt Follow-Up Care. Psychiatric Services. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900028

Psychiatric Advanced Directives. NAMI. https://www.nami.org/Advocacy/Policy-Priorities/Responding-to-Crises/Psychiatric-Advance-Directives.

Tuck, M. Wittowski, A., & Gregg, L. (November 2022) A Balancing Act: A Systematic Review and Metasynthesis of Family-Focused Practice in Adult Mental Health Services. Clinical Child and Family Psychology Review. https://link.springer.com/article/10.1007/s10567-022-00418-z

 Footnotes

[i] A Balancing Act: A Systematic Review and Metasynthesis of Family-Focused Practice in Adult Mental Health Services | SpringerLink

[ii] Psychiatric Advanced Directives. NAMI. https://www.nami.org/Advocacy/Policy-Priorities/Responding-to-Crises/Psychiatric-Advance-Directives.

[iii] Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Prompt Follow-Up Care | Psychiatric Services (psychiatryonline.org)

[iv] Frontiers | Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders (frontiersin.org)

[v] Frontiers | Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders (frontiersin.org)

[vi] (PDF) A Sustainability Model for Family-Focused Practice in Adult Mental Health Services (researchgate.net)

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