The Family Model: A brief intervention for clinicians in adult mental health services working with parents experiencing mental health problems

Introduction

The mental health (MH) and wellbeing of children are intimately linked to those of their parents (Falkov, 2012). Given the prevalence of mental illness in young people generally and the prevalence of parenthood among adults with mental illness, there are global public health implications for clinical practice and workforce development (Falkov et al., 2015).

Mental illness, parenting and children’s development are strongly connected. When an individual, regardless of age, experiences mental ill health, everyone in the family is affected. In turn, family members play a vital role in a person’s experience of illness (physical and/or mental). Ill health, therefore, has a critical and enduring influence on family life (Falkov, 2012).

These reciprocal influences between family members are insufficiently incorporated into daily practice (Foster et al., 2015). Given that psychiatric disorder in one or more individuals within families is a significant public health issue, providing clinicians and managers with tools and training to support this broader approach is an important component in establishing an MH workforce with knowledge and skills for family-focused, recovery-oriented support and treatment (Foster et al., 2015). Family-focused practice (FFP) broadens the target of care provision in MH services from a narrow focus on the MH consumer, to the wider family and caregiving system.

One such approach is provided by The Family Model (TFM), a visual tool which provides a framework to support care planning and recovery for families where parents experience mental illness in health/MH services (Falkov, 2012). TFM helps clinicians incorporate individual perspectives (both parent and young person) into family-focused care using a collaborative, non-judgemental process. This encourages balanced consideration of young people’s perspectives and those of key adults/parents when someone is unwell.

The emphasis is on the reciprocal links and influences in the relationships between family members, regardless of whether the affected individual is an adult, adolescent or infant. These relationships, which are a part of everyday family life, are also a key determinant of health outcomes for everyone in the family.

The focus of this paper is on the use of TFM as a brief (single-session) intervention for use by clinicians in AMH services.

Background

TFM has its origins in the Crossing Bridges programme, one of the earliest multi-disciplinary trainings for MH and social care professionals, on the impact of parental mental illness on children (Falkov, 2012). It formed the conceptual framework for the programme and provided an understandable and practical way of thinking about the impact of parental mental illness on children and how to support FFP. Since then, it has been extensively adapted and elaborated upon for direct (family-focused) work across a range of MH and children’s service settings (Falkov, 2015; www.thefamilymodel.com).

TFM has been shown to be acceptable to service users and providers and has been used in direct (family-focused) clinical work to provide balance in eliciting both the voice of the child and the need(s) of the ill parent (Hoadley et al., 2019).

The appeal appears to be the provision of an approach that supports collaborative practice and helps engage parents and family members. The emphasis on strengths as well as vulnerability and the visual nature of the approach enhances the traditional verbal therapeutic communication modality. An open-access eLearning course is available on the website (www.thefamilymodel.com).

Description

TFM consists of six domains and 10 bidirectional arrows, illustrated visually as a composite diagram, the components of which support FFP (see Figure 1). The domains and interconnecting arrows indicate the bi- and multi-directionality of impacts and influences in the interplay between symptoms, parenting and children’s development. Each domain is supported by an underlying principle and a developmental/longitudinal perspective is illustrated using multiple cross-sectional ‘slices’ of the TFM, details of which are available on the TFM website.

Figure 1.

The Family Model cross-sectional components (©Falkov, 2012).

The composite diagram supports a structured approach to care planning and recovery when engaging with the unwell person and one or more family members. The diagram (drawn on paper, a whiteboard or using a printed copy) forms the basis of a semi-structured dialogue between a clinician and one or more family members. The purpose is to acquire a shared understanding that supports a family-focused care plan.

The design and approach simplifies and distils a large amount of information (about parenting, child development, mental illness, relationships, resilience, vulnerability, service provision) that is directly relevant to an unwell individual’s experience of ill health and their relationship with key relatives (children; partner; carers/relatives). The combination of verbal and visual communication helps clinicians better appreciate the way(s) in which each person in the family system affects and is affected by every other person, whether ill or well.

TFM therefore provides a brief, accessible and practical approach to FFP that has been used over time by policymakers, trainers, researchers, managers and clinicians, in various ways and in different settings.

Clinical use in adult mental health settings (the ‘A5’ version)

TFM can be used in adult mental health (AMH) and child and youth mental health (CAMH/YMH) services, with all family members present or with just the adult/parent experiencing difficulties. There is a brief (single-session) version for clinicians in adult services working with a parent experiencing MH problems. This version helps ensure a family focus when working with just the affected person.

There is a convenient (A5 size) printed/laminated card with TFM diagram on one side and a series of questions (relevant to each of the six domains) on the other side (Figure 2). The domains and arrows help guide the conversation and the questions can serve as prompts for clinicians who may be anxious about having this sort of conversation in which the focus is on the experience of parenting, the wellbeing of children and the strengths shown by the individual despite being unwell.

Figure 2.

The Family Model ‘A5 card’ (page 2).

This facilitates FFP by keeping children in mind when working with the individual adult/parent. The aim is for clinicians to undertake a semi-structured, collaborative conversation with the consumer/service user to develop a family-focused care plan. The card can be given to the parent, supporting collaborative practice and shared endeavour.

There is an open-access eLearning foundation course available on the TFM website which provides training about TFM and how to use the single-session version (A5 card) to develop a family care plan.

Domains and arrows

Domains 1 and 2 represent the needs of the adult/parent and children, respectively. Both are valid. These transgenerational connections are illustrated by arrows between Domains 1 and 2. Domain 2 gives ‘permission’ to ask about children and Domain 1 ensures that an adult/parent wish to do the best for their children is acknowledged.

Domain 3 helps demonstrate the importance of relationships and communication between a parent and child(ren), for example, talking about children’s understanding of parental symptoms and the impact, as well as how best to support both parenting and children’s needs. This approach shows that it is possible to be family focussed even when children or other family members are not present.

The apportioning of equal visual ‘space’ to strengths/resilience as well as struggles/vulnerability (Domain 4) ensures a balanced approach, with opportunity to validate parental achievement/commitment to doing the best for their children (despite adversity/crisis).

The service element (Domain 5) ensures explicit recognition of the interface between service users/consumers and providers. This supports FFP by bringing clinicians, parents and children/relatives closer to ‘common ground’ and a level-playing field, thereby helping practitioners recognise their own role and what they bring to the clinical encounter.

It also reminds clinicians about cultural aspects and influences more distal to immediate individual and family factors (Domain 6).

The provision of shared values and a common (visual) language have been further useful accompaniments to supporting FFP. In this sense, it has proven itself useful as both a clinical and an educational tool for all staff including managers, supervisors and trainers (Falkov, 2015).

Conclusion/summary

TFM’s inclusive focus ensures that the needs of the (unwell) individual include parenting as well as children and relatives. Acknowledging strengths (not just vulnerabilities), together with cultural and community influences, suggests an appropriate theoretical justification for its use as a tool supporting FFP. This practical framework can inform clinical work and provide practitioners with options for conducting joint conversations with a parent about parenting and their children’s needs, as well as working with other family members. In doing so, it harnesses the collective expertise of family members’ lived experience and practitioners’ clinical expertise and supports active involvement in developing collaborative family-focused care plans.