Visions Journal

Robert Lees, Ed.D, R.Psych

Reprinted from the Supporting Parents issue of Visions Journal, 2021, 17 (1), pp. 5-7

Around 1997, a group of like-minded health and social service providers connected to form an organization we called the Provincial Working Group on Supporting Families with Parental Mental Illness. All group members had seen that the mental health system focused primarily on individuals, often neglecting the important role that families can play in treatment. For many of us, the interest was in ensuring that mental health professionals recognized and met the needs of children who had parents with mental illness.

Now, almost 25 years later, I wonder if there has really been any advancement towards this objective. At the time, most studies suggested that one in five schoolchildren had a parent with a mental illness. In the 1990s, we heard stories of parents admitted to psych wards and no one speaking to the children about what that meant. We heard of parents who died by suicide and no one speaking with the children about understanding mental illness or inquiring about their needs.

The working group spent considerable time, off the corners of desks, developing resources and advocating. Our vision including developing what were known as the four Ps: protocols, practices, policies and programs. We foresaw the need for regular community training forums that would sensitize and build skills in family based practice. Eventually, we developed a community forum training manual.¹

Recently, a colleague who manages a mental health and addiction service said, We do pretty good at patient-centred care but not so good at family-centred care.” A litmus test I use is whether, when adults are admitted to psychiatry, anyone asks about the functioning of the family and the welfare of the children—and then responds. Given my experience, I don't think we've come very far.

Family centred care is a complex topic and initiative, but at its core it means asking about family relations, including family members in treatment, and recognizing that the mental health needs of one have a ripple effect throughout the family system—generations up, and down.

The evidence base for this practice area is limited, which in itself suggests slow progress towards adopting a more family-centric practice model. A 2016 report of audits of adult, child and adolescent mental health files found that "none of the services included in the authors' study appeared to have effective methods in place to detect the presence of parental mental illness and assess the children affected by it."²

Including families in the response to the opioid crisis

The opioid crisis, which has taken a staggering number of lives, has not only affected individuals but whole family systems. While the interest is rightly in attempting to prevent overdose deaths, there is also an enormous need to work with these whole systems towards healing. The youth health clinic in Chilliwack, where I work, has seen a surprising number of teenagers and young adults grappling with grief related to the loss of a parent to drug overdose. The shame associated with addiction often makes this a silent suffering for family members. While my colleagues in addiction services have worked harder than most to respond to the needs of those affected by the addiction of another, I have never heard of a post-intervention service for the hundreds of families affected by these complicated losses.

Understanding perverse incentives

Very often compensation systems for mental health professionals, including psychiatrists and physicians, are dedicated towards individual-focused care only. Of course, considerations related to privacy and autonomy are at play, but many readers will have had the experience of visiting their family doctor and being told to speak about one problem per visit. This is a perverse incentive against even a holistic individual perspective, never mind consideration of relationships and family functioning.

I work in a setting providing care to young people ages 12-26. I frequently need to remind training counsellors that it is preferable, if the young person will agree, to involve the family in counselling. What they find immediately is a multiplication of variables involved: take the "bio-psycho-social-spiritual" model of assessment, which is meant to be a platform for case conceptualization, capturing the breadth of human experience, and multiply it by the number of people in the room. This is difficult just in terms of office space and booking appointments. In other words, it is harder work and requires special preparations and skill. So there are perverse incentives to only work one-on-one with youth.

Acknowledging adverse childhood experiences

There is growing awareness among medical and mental health professionals of the role played by so-called "ACEs," or adverse childhood experiences, in creating trauma, and the role trauma plays in mental illness. The Adverse Childhood Experience Questionnaire³ comprises 10 questions, all of which relate to experiences in the family. Of course, biological factors implicated in serious and persistent mental illness are extremely important and are known to play a significant role in illnesses such as schizophrenia and bipolar disorder. However, they are only part of the story. It is easy to see how ACEs can create anxiety, depression, toxic stress and post-traumatic stress. If much of the origin of illness is based in family functioning, then it stands to reason that the path to healing is in supporting and healing families.

Advocating for family-centred care

Perhaps I am myopic, but from my lens as a provider, it is the not-for-profit organizations that advocate for family-centred care, including the BC Schizophrenia Society, FamilySmart, Canadian Mental Health Association and others like them. These are the least securely or well-funded parts of the whole mental health system. The future of these organizations is precarious, depending as it does on the favour of politicians and bureaucrats. Nevertheless, because they are so often directly bound to the lived experience of families, they see a more holistic picture that gets missed in only patient-centred care. For example, a partner agency I know, a women's domestic violence shelter organization, includes couples and family counselling, thus expanding their mandate to address root causes of relationship dysfunction. Sadly, I believe they are a rarity.

Finding the balance

While patient-centred care should always be an important standard, in my view, the system is heavily imbalanced. We need incentives that lead to practices for family healing and support. We need incentives for psychiatry wards to employ family therapists, and payment schemes that reward family doctors and psychiatrists for spending office time with families. We need training for mental health and medical professionals to ensure they feel competent dealing with the increased complexity demanded by family work.

We also require massive investments in prevention work with families that will ensure equal or greater return in dollars saved and lives spared the pain of psychological and mental distress. We need a long view. As one of my clients used to say, there are no shortcuts, just dumb cuts and smart cuts. Let's make the smart cut—invest in family mental health in a big way.