Family-inclusive approaches when working with young people accessing mental health support

Family-inclusive approaches when working with young people accessing mental health support

1 April 2022
The preadolescent boy gestures as he explains to his mother what happened.

This short article provides evidence on family-inclusive approaches when working with young people who are accessing mental health support.

Legislation dictates how families should be included when young people legally regarded as a minor (under 18 years) access mental health supports. Common law and some state laws provide for children under 18 years to be able to consent to treatment if they have sufficient ‘maturity and understanding’.32 Legislation should be considered alongside the evidence and practice guidance outlined in this short article.

Introduction

Understanding family context and appropriately including family members when providing mental health support to young people can improve engagement with services and increase overall wellbeing.1,2,3,4,5,6 Although practitioners often understand the benefits of family inclusion when working with young people, it can be challenging to balance a young person’s right to privacy with family-inclusion guidance.1,2,7,8,9 This short article describes family-inclusive approaches and outlines the evidence that supports practitioners to include families when working with young people accessing mental health support.

What are family-inclusive approaches?

Family-inclusive approaches support young people to include their family context and members in care assessments, planning and treatment when accessing mental health support.2,10,11 In mental health services, it’s recognised that the inclusion of family members is helpful for young people aged 12-25, particularly if they live with family.7 Evidence supports adopting a broad definition of family and listening to young people’s definition of who they consider ‘family’ and their key support network.3,7

Many terms are used interchangeably to talk about family-inclusive approaches (e.g., family-focused practice,3,12 family-centred practice and approaches13) with a lack of clarity on the level of family inclusion being described.4 Despite inconsistent terminology, all terms adhere to some common principles:3

  • Whole-of-family context: Understanding family context and relationships is essential to supporting a young person’s mental health needs.
  • Strengths-based perspective: Practitioners recognise that young people and their families have, and can develop, skills to support their mental health needs and recovery.
  • Families can provide support: Family members are often a young persons’ closest social relationship. Young people can receive effective support through their family members.
  • Communication and collaboration: Regardless of the level of direct family involvement with the approach, communication between practitioners, clients and their families should be collaborative and respectful.
  • All families are unique: The culture and language traditions of each family should be respected and diversity across and within families should be appreciated.3,13,14

Family-inclusive approaches exist along a continuum, from acknowledging that young people’s lives occur in a broader social context to specific practices that include families in decision making or provide family members with direct support.3,5,12,13,15 Including family will look different for each young person and there may be instances when it is not appropriate to directly include family members due to safety concerns or unreasonable behaviour.33 Family-inclusive principles and approaches can support practitioners to consider a young person’s care within the broader family context without direct contact with family.24

Family-inclusive approaches for young people accessing mental health support

When accessing mental health support, young people’s right to privacy and participation in decision making can lead to practitioner concerns around confidentiality,1,2,7,16,17 and young people can feel worried about family reactions and stigma.1,7,16,17 However, Australian and international systematic reviews present strong evidence that understanding family contexts and including family with a client’s consent leads to positive outcomes in a range of health and welfare settings.4,6,18,19,20,21

In the context of young people accessing mental health support, small-scale Australian and international studies find that family-inclusive approaches can improve a young person’s quality of life,1 reduce levels of anxiety,22 reduce relapse rates,3,15 and increase carer capacity and understanding.15,16 However, a recent UK and Australian systematic review highlights that consistent quality assessment is needed across adolescent mental health services generally to better evaluate the effectiveness of approaches.17 Better evaluation can support practitioners to understand which family-inclusive approaches are most effective when working with young people.

Australian and international evidence supports the following family-inclusive approaches when working with young people accessing mental health support. These approaches are not mutually exclusive and can overlap but are all underpinned by family-inclusive principles.3

 
Family-inclusive approach Details Supporting evidence
Psychoeducation for family members Psychoeducation provides mental health information to family members to support their understanding of the young person’s mental health challenges, including building support skills and learning how to manage their own stress and mental health.3,6,12,13 This can be general information or specific to a young person’s diagnosis or treatment.3 While there is strong evidence for using psychoeducation as part of a family-inclusive approach,6,16,23,24 some practitioners report that it can be time consuming to implement.5 3,4,6,10,12,22,23,24,25,28
Instrumental, emotional and social support for family members Foster et al. (2016) identified that families can benefit from instrumental (practical support; e.g., help with referrals), social (support to expand social networks), and emotional support (being empathetic towards family members) when a service user is experiencing mental health challenges. These types of support can encompass a range of practices where help is provided directly to family members, not via the service user.3 3,4,6,16,25,
Coordinated care between families and mental health support Coordinated care, sometimes referred to as integrated care, is inherently collaborative between services, young people and their families. This means that services see young people and their families as important members of the ‘team’. Specific examples include ‘Wraparound’ services or a ‘warm handoff’ between services.3,6 3,4,6,15
Information sharing between family and services Information sharing is a two-way process where practitioners provide information about a young person’s diagnosis and treatment to families, and families provide information about their family context to practitioners. This has been identified as an important practice for assessing suicide risks in clinical settings.18 4,8,18
Family care planning, including goal setting Family care planning considers family members in the development of a young person’s care plan, helps family members understand how to contribute to a young person’s care plan and how to respond in a crisis. Families also set their own goals to support a young person’s recovery and consider their own mental health.3 3,4
Single Session Family Consulting Single Session Family Consulting (SSFC), developed by The Bouverie Centre, is a brief intervention where practitioners meet clients and family members together for 1–3 sessions to collaborate on how they can be included in a young person’s treatment, assess needs, answer questions and provide information.1,5,26,27 Brief interventions such as SSFC may not be suitable for managing more complex mental health presentations; for example, young people with psychosis, disruptive behaviour problems or acute crisis.27,28 1,5,10,26,27,30
The Family Model The Family Model (TFM) is a framework that supports practitioners to implement family-inclusive practice.29 TFM helps to understand the connections and relationships within families and between families and services using diagrams.29 An Australian study recently explored TFM with child mental health service practitioners and found that practitioners reported better understandings of family relationships and challenges when using TFM.29,30 2,29,30
Family assessment Family assessment supports practitioners to understand a young person’s family context. It can include mapping a young person’s relationships or genograms.7 The assessment can be carried out with the young person over multiple sessions by asking questions about their family context and relationships. Assessments can also be carried out with family members to support understanding of parenting skills, mental health literacy and the effect of mental illness on the family.3,7 3,7

What are the evidence-based implications for practice?

The following considerations have been shown to support the implementation of family-inclusive approaches:

Partial consent

It is not necessary to include families in every aspect of a young person’s treatment.3,9 Practitioners can provide general information to families on how to support people’s mental health without providing personal information.3,10 Discussing partial consent and regularly reviewing agreements with young people can support family inclusion and build trust, while acknowledging potential privacy concerns.3,7

Person-centred approach

A person-centred approach places the young person, their choices and strengths at the centre of the approach.4,16 Person-centred approaches can support family-inclusive approaches,16 empowering young people to communicate their desired outcomes and make decisions about their treatment, including levels of family inclusion.1,4,6,16

Workforce education and training

Training courses for practitioners can increase staff confidence and competence in selecting and delivering family-inclusive approaches.3,4,15 Sawrikar and colleagues (2021) found that providing training on family engagement led to an increase in practitioner confidence and ability to include fathers who are often excluded from family-inclusive approaches and treatment interventions.31

Organisational culture and policies

To effectively implement family-inclusive approaches, practitioners need support from an organisation’s culture and processes.8,15,29 Updating organisational policies to encourage and reflect family-inclusive principles can help implement consistent practice; for example, including policies around flexible appointment times after school and work hours.3,6 Practitioners also need sufficient time and resources to be able to engage family members effectively.10

Online services and telehealth

Online or telehealth support can provide accessible opportunities to deliver family-inclusive approaches, such as instrumental support.6,24,28 Single session family consulting follow-up phone calls with families have also been shown to be beneficial.5

Conclusion

Australian and international evidence shows that when family is included meaningfully in a young person’s care planning and treatment, it can lead to positive outcomes for service users and their families.1,2,3,4,5,6 When young people are supported to include their family, it can lead to a higher likelihood of continued treatment, reduced rates of relapse, reduced anxiety, improved satisfaction with care and increased overall wellbeing.1,2,3,15,22

Further reading and related resources

Family and friends inclusive practice handbook
This handbook by headspace provides guidance on how to provide family-inclusive practice, including how to talk to young people and their family about family inclusion.

Family inclusion in mental health and related areas
The Bouverie Centre develops practice models, training, and resources to support services to understand and implement family-inclusive practices.

A practical guide for working with carers of people with a mental illness
This guide by Mind Australia provides practical guidance on how to work with families of people with a mental illness.

Fact sheet – Infant child and youth mental health and wellbeing services
The Royal Commission into Victoria’s Mental Health System provides a fact sheet on Infant, child and young mental health and wellbeing services including recommendations for best practice.

Single Session Family Consultation practice manual
This website by The Bouverie Centre provides information on ways to implement Single Session Family Consultation.

References

1. Coates, D. (2016). Client and parent feedback on a youth mental health service: The importance of family inclusive practice and working with client preferences. International Journal of Mental Health Nursing, 25(6), 526–535. doi.org/10.1111/inm.12240

2. Hoadley, B., Smith, F., Wan, C., & Falkov, A. (2017). Incorporating children and young people’s voices in child and adolescent mental health services using the family model. Social Inclusion, 5(3), 183–194. doi.org/10.17645/si.v5i3.951

3. Foster, K., Maybery, D., Reupert, A., Gladstone, B., Grant, A., Ruud, T. et al. (2016). Family-focused practice in mental health care: An integrative review. Child & Youth Services, 37(2), 129–155. doi: 10.1080/0145935X.2016.1104048

4. Park, M., Giap, T., Lee, M., Jeong, H., Jeong, M., & Go, M. (2018). Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews. International Journal of Nursing Studies, 87, 69–83. doi.org/10.1016/j.ijnurstu.2018.07.006

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6. Waid, J., & Kelly, M. (2020). Supporting family engagement with child and adolescent mental health services: A scoping review. Health & Social Care in the Community, 28(5), 1333–1342. doi.org/10.1111/hsc.12947

7. National Youth Mental Health Foundation (headspace). (2014). Family and friends inclusive practice handbook [Handbook]. Retrieved from headspace.org.au/assets/clinical-toolkit/headspace-handbook-Family-and-friends-inclusive-practice.pdf

8. Marynowski-Traczyk, D., Broadbent, M., Kinner, S. A., FitzGerald, G., Heffernan, E., Johnston, A., Young, J. T. et al. (2019). Mental health presentations to the emergency department: A perspective on the involvement of social support networks. Australasian Emergency Care, 22(3), 162–167. doi.org/10.1016/
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10. Baker, D., Burgat, L., & Stavely, H. (2019). We’re in this together: Family inclusive practice in mental health services for young people. Parkville, Vic.: Orygen. Retrieved from www.orygen.org.au/Policy/Policy-Areas/Government-policy-service-delivery-and-workforce/Service-delivery/We-re-in-this-together/Orygen_We-re-all-in-this-together_2019.aspx?ext=.

11. Royal Commission into Victoria’s Mental Health System (RCVMHS). (2021). Final report, volume 3: Promoting inclusion and addressing inequities (Parl. Paper No. 202, Session 2018–21). Melbourne: State of Victoria. Retrieved from finalreport.rcvmhs.vic.gov.au/wp-content/uploads/2021/02/RCVMHS_FinalReport_Vol3_
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12. Allchin, B., Weimand, B. M., O’Hanlon B., & Goodyear, M. (2022). A sustainability model for family-focused practice in adult mental health services. Frontiers in Psychiatry, 12, 761–889. doi:10.3389/fpsyt.2021.761889

13. Maybery, D., Foster, K., Goodyear, M., Grant, A., Tungpunkom, P., Skogoy, B. E. et al. (2015). How can we make the psychiatric workforce more family focused? In A. Reupert, D. Maybery, J. Nicholson, M. Gopfert, & M. V. Seeman (Eds.), Parental Psychiatric Disorder: Distressed Parents and their Families (3rd ed., pp. 301–311). Cambridge University Press.

14. Dunst, C., Trivette, C., & Hamby, D. W. (2007). Meta-analysis of family-centered helpgiving practices research. Mental Retardation and Developmental Disabilities Research Reviews, 13(4), 370–378.

15. Shah-Anwar, S., Gumley, A., & Hunter, S. (2019). Mental health professionals’ perspectives of family-focused practice across child and adult mental health settings: A qualitative synthesis. Child & Youth Services, 40(4), 383–404. doi: 10.1080/0145935X.2019.1591947

16. Gondek, D., Edbrooke-Childs, J., Velikonja, T., Chapman, L., Saunders, F., Hayes, D. et al. (2017). Facilitators and barriers to person-centred care in child and young people mental health services: A systematic review. Clinical Psychology and Psychotherapy, 24, 870–886. doi:10.1002/cpp.2052

17. Quinlan-Davidson, M., Roberts, K. J., Devakumar, D., Sawyer, S., Cortez, R., & Kiss, L. (2021). Evaluating quality in adolescent mental health services: A systematic review. BMJ Open, 11(044929). doi: 10.1136/bmjopen-2020-044929

18. Wyder, M., Ray, M. K., Roennfeldt, H., Daly, M., & Crompton, D. (2020). How health care systems let our patients down: A systematic review into suicide deaths. International Journal for Quality in Health Care, 32(5), 285–291. doi: 10.1093/intqhc/mzaa011

19. McCalman, J., Heyeres, M., Campbell, S., Bainbridge, R., Chamberlain, C., Strobel, N. et al. (2017). Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: A systematic scoping review. BMC Pregnancy and Childbirth17(1), 71. doi.org/10.1186/s12884-017-1247-2

20. Scully, C., McLaughlin, J., & Fitzgerald, A. (2020). The relationship between adverse childhood experiences, family functioning, and mental health problems among children and adolescents: A systematic review. Journal of Family Therapy, 42, 291–316. doi.org/10.1111/1467-6427.12263

21. Hayes, D., Edbrooke-Childs, J., Town, R., Wolpert., M., & Midgley, N. (2021). A systematic review of shared decision making interventions in child and youth mental health: Synthesising the use of theory, intervention functions, and behaviour change techniques. European Child & Adolescent Psychiatry. doi.org/10.1007/s00787-021-01782-x

22. Goger, P., & Weersing, V. R. (2022). Family based treatment of anxiety disorders: A review of the literature (2010–2019). Journal of marital and family therapy, 48(1), 107–128. doi.org/10.1111/jmft.12548

23. Backhaus, R., Hoek, L. J. M., de Vries, E., van Haastregt, J. C. M., Hamers, J. P. H., & Verbeek, H. (2020). Interventions to foster family inclusion in nursing homes for people with dementia: A systematic review. BMC Geriatrics, 20(1), 434. doi: 10.1186/s12877-020-01836-w

24. Bordelon, A. E., & Bradley, R. L. (2019). Family inclusion. In R. Rieske (Ed.), Handbook of Interdisciplinary Treatments for Autism Spectrum Disorder (pp. 445–463). Cham, Switzerland: Springer. doi.org/10.1007/978-3-030-13027-5_24

25. Westwater, J., Murphy, M., Handley, C., & McGregor, L. (2020). A mixed methods exploitation of single session family therapy in a Child and Adolescent Mental Health Service in Tasmania, Australia. Australian and New Zealand Journal of Family Therapy, 41, 258–270. doi.org/10.1002/anzf.1420

26. Foster, T. D., Decker, K. B., Vaterlaus, J. M., & Belleville, A. (2020). How early intervention practitioners describe family-centred practice: A collective broadening of the definition. Child: Care, Health and Development, 46(3), 268–274.doi.org/10.1111/cch.12749

27. Fry, D. (2012). Implementing Single Session Family Consultation: A reflective team approach. Australian and New Zealand Journal of Family Therapy, 33, 54–69. doi.org/10.1017/aft.2012.6

28. Sheidow, A. J., McCart, M. R., & Drazdowski, T. K. (2022). Family-based treatments for disruptive behavior problems in children and adolescents: An updated review of rigorous studies (2014–April 2020). Journal of Marital and Family Therapy, 48(1), 56–82. doi.org/10.1111/jmft.12567

29. Grant, A., Falkov, A., Reupert, A., Maybery, D., & Goodyear, M. (2020). An exploration of whether mental health nurses practice in accordance with The Family Model. Archives of Psychiatric Nursing, 34(4), 244–250. doi.org/10.1016/j.apnu.2020.04.003

30. Hoadley, B., Falkov. A., & Agalawatta., N. (2019). The acceptability of a single session family focused approach for children/young people and their parents attending a child and youth mental health service. Advances in Mental Health, 17(1), 44–54. doi:10.1080/18387357.2018.1480398

31. Sawrikar, V., Plant, A. L., Andrade, B., Woolgar, M., Scott, S., Gardner, E. et al. (2021). Global workforce development in father engagement competencies for family-based interventions using an online training program: A mixed-method feasibility study. Child Psychiatry & Human Development. doi.org/10.1007/s10578-021-01282-8

32. Gillick v West Norfolk and Wisbech AHA (1986) AC 112.

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Featured image: © GettyImages/ SDI Productions

Authors

Cat Strawa

Cat Strawa is a Senior Research Officer in the Child and Family Evidence team.

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