Embedding sustainable family-focused practice in your organisation

Mental health interventions and models have been developed and researched for use in a variety of settings and contexts, resulting in a wide range of evidence-based and manualised programs. However, they are commonly developed and implemented in the context of time-limited projects or research trials. This can make embedding interventions and models in everyday practice less likely and create issues in the pipeline model of evidence translation. Without organisational awareness and subsequent practice change, the likelihood of families having access to the known benefits of these programs is limited (Allchin, Weimand, O’Hanlon, & Goodyear, 2022).

The success of mental health interventions is commonly measured based on adherence to key tasks and activities. The link between these tasks/activities and the evidence-based outcomes needs to be clearly articulated to ensure any intervention program adaptations won’t threaten fidelity in practice (Escoffery et al., 2018; Kirk et al., 2019), which can challenge introduction and sustainability of these interventions into everyday practice. The successful use of an intervention program will depend on the practice setting, and usually requires adjustments to the setting and/or the intervention to ensure it fits within organisational structures and workflows (Allchin, Weimand, O’Hanlon, & Goodyear, 2022).

While experiences such as mental health difficulties, financial instability, insecure housing or employment, substance use, and family and domestic violence can have multigenerational impacts on families, there is strong evidence that it is possible to promote family wellbeing and mitigate and/or prevent mental ill-health in children from developing.

When families face serious life challenges, their relationships and ways of being are disrupted, and all family members can be impacted (Walsh, 2016b). To effectively understand and respond to family needs in the context of their daily lives, new organisational approaches are needed.

New organisational approaches

For sustained practice change to occur, an in-depth understanding of the following is required:

• the practice setting
• the funding and policy context
• practitioners’ everyday practice; and
• the population served by the setting.

Use of evidence-informed approaches to design localised, relevant practice models and sustainable interventions are seen in adaptation approaches in the ‘It takes a village approach’ in Innsbruck, Austria (Goodyear et al., 2021), the ParentingWell Practice approach in Massachusetts, USA (Nicholson, Heyman, English, & Biebel, 2022) and Let’s Talk About Children in Finland (Allchin & Solantaus, 2022). These models of family-focused practice which support families where a parent has a mental illness all share common elements that address components of family resilience processes. However, all have been built or adapted to work and fit within the local service systems of the respective countries and regions.

Understanding the facilitators and constraints of the practice setting, and the needs of its practitioners and the population being served, enables co-development of setting-specific activities and can promote the use of appropriate key resilience processes. With this understanding, the mechanisms that create change can be applied by integrating a range of activities into everyday practice, supporting practitioners and parents by allowing for flexibility in how the interventions are delivered.

Through an iterative monitoring process organisations can ensure the activities use the evidence-based mechanisms of change and provide the intended outcomes.

While co-developing evidence-informed practice increases its likelihood of fitting the setting and being sustained, its sustainability depends on organisations (Allchin et al., 2022). Practice settings are complex and dynamic, adapting to changes in:

• external funding
• policy structures
• internal personnel; and
• internal structures.

Within this changing environment, sustainability relies on organisations making the changes necessary for consistent, family-focused practice delivery (Allchin et al., 2022). Sustainability literature notes that to sustain family-focused practice an organisation must have the capacity for:

• organisational ownership, with both authorising leadership and leadership to support integration on the ground
• supportive operational systems that enable data collection systems, feedback loops and communication systems; and
• practitioner capability building, including systems for training, mentoring and support (Allchin et al., 2020; Allchin et al., 2022).

These elements are all interrelated and require attention in an iterative and ongoing process to create an environment that supports and sustains practice change.

Sustainable practice change also depends on how evidence-informed practices are understood and articulated. This involves examining the evidence in the context of how the activities/tasks work to create the desired outcomes, thus enabling an articulation of the key elements and mechanisms of change separate from the discrete manualised activities. When this is understood, the key elements of change can be more easily applied to different settings, increasing the likelihood of them being embedded and sustained in everyday practice.

While few evidence-based, family-focused interventions articulate the theory of change embedded within their activities (Goodyear et al., 2021), family resilience literature focuses on key processes that support families to manage the impact of stressors on everyday family life (Walsh, 2016a). The key resilience processes are clustered within three family systems:

• the family’s belief system – making meaning out of adversity, having a positive outlook, transcendence/spirituality
• the family’s organisational patterns – flexibility, connectedness, access to social and economic resources; and
• the family’s communication systems – clarity, open emotional expression and collaborative problem solving (Walsh, 2003, 2016a, & 2016b).

These key family resilience processes commonly underpin evidence-based, family-focused interventions. While discrete family-focused interventions package these processes in different sets of tasks and activities, evidence-based interventions generally include:

• expanding families’ social networks
• enhancing families’ communication and problem solving
• building parental self-efficacy and self-determination
• promoting the child voice and agency
• re-establishing routines
• linking families to adequate resources; and
• promoting parent–child co-regulation for healthy child development (Marston et al., 2016; Radley, Grant, Barlow, & Johns, 2021).

By applying these key processes to everyday practice, practitioners could provide families facing adversity with access to the supports they need to bolster their mental health and resilience.

Each organisation is on a unique journey, building on what already exists. Emerging Minds’ new self-directed organisational resources can support your organisation to reflect on what is needed to build the sustainability of family-focused practice in your setting to support the social and emotional wellbeing and mental health of children and families.

Allchin, B., O’Hanlon, B., Weimand, B. M., Boyer, F., Cripps, G., Gill, L., Paisley, B., Pietsch, S., Wynne, B., & Goodyear, M. J. (2020). An explanatory model of factors enabling sustainability of Let’s Talk in an adult mental health service: A participatory case study. International Journal of Mental Health Systems, 14, 48. DOI: 10.1186/s13033-020-00380-9

Allchin, B., & Solantaus, T. (2022). An evidence-based practice developed in-situ: Let’s Talk about Children and a consolidation of its evidence base [brief Research Report]. Frontiers in Psychiatry, 13, 824241. DOI: 10.3389/fpsyt.2022.824241

Allchin, B., Weimand, B. M., O’Hanlon, B., & Goodyear, M. (2022). A Sustainability Model for Family-Focused Practice in Adult Mental Health Services [Perspective]. Frontiers in Psychiatry, 12, 761889. DOI: 10.3389/fpsyt.2021.761889

Escoffery, C., Lebow-Skelley, E., Haardoerfer, R., Boing, E., Udelson, H., Wood, R., Hartman, M., Fernandez, M. E., & Mullen, P. D. (2018). A systematic review of adaptations of evidence-based public health interventions globally. Implementation Science, 13, 125. DOI: 10.1186/s13012-018-0815-9

Goodyear, M., Zechmeister-Koss, I., Bauer, A., Christiansen, H., Glatz-Grugger, M., & Paul, J. L. (2021). Development of an evidence-informed and codesigned model of support for children of parents with a mental illness – “It takes a village” approach [original research]. Frontiers in Psychiatry, 12, 806884. DOI: 10.3389/fpsyt.2021.806884

Kirk, M. A., Haines, E. R., Rokoske, F. S., Powell, B. J., Weinberger, M., Hanson, L. C., & Birken, S. A. (2019). A case study of a theory-based method for identifying and reporting core functions and forms of evidence-based interventions. Translational Behavioral Medicine, 11(1), 21–33. DOI: 10.1093/tbm/ibz178

Marston, N., Stavnes, K., Van Loon, L. M. A., Drost, L. M., Maybery, D. J., Mosek, A., Nicholson, J., Solantaus, T., & Reupert, A. E. (2016). A content analysis of Intervention Key Elements and Assessments (IKEA): What’s in the black box in the interventions directed to families where a parent has a mental illness? Child & Youth Services, 37(2), 112–128. DOI: 10.1080/0145935X.2016.1104041

Nicholson, J., Heyman, M., English, K., & Biebel, K. (2022). The ParentingWell practice approach: Adaptation of Let’s Talk About Children for parents with mental illness in adult mental health services in the United States [original research]. Frontiers in Psychiatry, 13, 801065. DOI: 10.3389/fpsyt.2022.801065

Radley, J., Grant, C., Barlow, J., & Johns, L. (2021). Parenting interventions for people with schizophrenia or related serious mental illness. Cochrane Database of Systematic Reviews (10). DOI: 10.1002/14651858.CD013536.pub2

Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42(1), 1–18. DOI: 10.1111/j.1545-5300.2003.00001.x

Walsh, F. (2016a). Family resilience: A developmental systems framework. European Journal of Developmental Psychology, 13(3), 313–324. DOI: 10.1080/17405629.2016.1154035

Walsh, F. (2016b). Strengthening family resilience (3rd ed.). New York: Guilford Press.