Building bridges over troubled water: A qualitative evaluation of an implementation study on family involvement in the treatment of persons with psychotic disorders

Abstract

Relatives of persons with psychotic disorders provide important informal care. Systematic family interventions consistently demonstrate positive patient outcomes, and have also been found significant for the relatives themselves. Therefore, systematic family involvement is recommended as part of standard treatment. However, despite robust evidence, strong socio-economic arguments, and clear recommendations in guidelines, implementation remains poor.

Nested within the Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP)-study, this thesis contributes with new knowledge about processes that may influence the implementation of systematic family involvement in mental health care for persons with psychotic disorders. Through semi-structured focus group interviews with health personnel and leaders, and individual patient interviews, we examined barriers and facilitators to the implementation of family involvement, ethical challenges related to the duty of confidentiality, and patient experiences with family involvement.

We identified several barriers at the clinical and organisational level, and this thesis provides in depth knowledge on how to better deal with these barriers and challenges. Taking a whole-ward and multi-level approach where all mental health professionals receive training, supervision and practice in systematic family involvement, seem to strengthen implementation. Furthermore, all patients with psychotic disorders and their relatives should be offered basic family involvement at an early phase of their illness trajectory. Investing in the engagement phase is important, as several core barriers, such as lack of consent and the duty of confidentiality, were particularly evident during this phase. Other key facilitators seem to be organisational- and leadership commitment, flexible standardisation, and taking a step-wise process to family involvement, that is starting with the most basic and then later introduce more advanced interventions.

At the clinical level, the IFIP implementation intervention seemed to create a shift in awareness, attitudes, understanding and clinical practices in favor of family involvement. When competence and experience increased, ethical dilemmas and other barriers became less demanding to handle. The clinical interventions seemed to change negative circles in the triadic collaboration to positive circles through better understandings and awareness of each other’s situation, increased trust and support, and better coping with the illness. The thesis also provides in-depth insight into possible mediators of positive outcomes for the patients and the relatives.

Our findings indicate that mental health professionals are often faced with unrealistic expectations when required to offer systematic family involvement without adequate training, supervision, and routines. It also seems like the implementation resources and competence required to implement systematic family involvement are insufficient. The findings are likely to be relevant for future policy development, health education, implementation, health legislation, professional ethics and clinical practice when providing family involvement in line with the national guidelines.