doc daimler only

ORIGINAL PAPER

Family Influence in Recovery from Severe Mental Illness

Heather Michelle Aldersey • Rob Whitley

Received: 24 February 2014 / Accepted: 19 November 2014 / Published online: 10 December 2014

� Springer Science+Business Media New York 2014

Abstract The aim of this study was to investigate the

perceived influence of family on recovery from severe

mental illness. 54 semi-structured interviews were con-

ducted with a diverse sample of people with severe mental

illness living in Montreal. Results indicated that family

both facilitated and impeded recovery processes. Specifi-

cally, family facilitated recovery through providing

(a) moral support, (b) practical support and (c) motivation

to recover. However family impeded recovery through

(a) acting as a stressor, (b) displaying stigma and lack of

understanding, and (c) forcing hospitalization. The study

indicates the importance of family psychoeducation in

promoting recovery.

Keywords Recovery � Family � Severe mental illness � Canada � Quebec

Introduction

In recent years, definitions of recovery from severe mental

illness (SMI) have shifted from clinical perspectives

emphasizing symptom remission to more holistic per-

spectives that emphasize social and functional aspects of

life (Whitley and Drake 2010). In this context, recovery has

been defined as ‘‘living a satisfying, hopeful, and

contributing life, even when there are on-going limitations

caused by mental health problems’’ (Mental Health Com-

mission of Canada 2012, p. 15). In this sense, recovery is

an ongoing individual process toward improved quality of

life. This shifting perspective on recovery was led by

consumer/survivor groups seeking greater empowerment,

destigmatization and renewed hope for their future (Lefley

1997).

Much research indicates that aspects of the social

environment impact recovery from severe mental illness

(Schon et al. 2009; Topor et al. 2011). This research has

focused on areas including employment (Becker and Drake

2003), housing (Padgett 2007) and social connectedness

(Ware et al. 2007). One life domain which has received less

attention in the literature is the role of family. This may

represent an unwillingness amongst psychiatric researchers

to reopen a line of enquiry that was historically criticized

for implicitly stigmatizing, damaging and attacking family

members of people with mental illness (Luhrmann 2007).

This includes the now discredited notion of the

‘‘schizophrenogenic mother’’, which attributed mental ill-

ness to maternal overprotection and rejection (Bateson

et al. 1956; Neill 1990). These now outmoded views were

rooted in Freudian notions of dysfunctional family rela-

tionships being critical to mental illness onset, as well as

the post-war ‘liberation’ movements which perceived

families, especially parents, as a poisonous influence on

young adults (Laing 1967; Guarnaccia 1998). These

notions were rendered obsolete by careful research exam-

ining the relationship between parenting style and schizo-

phrenia (e.g. Hirsch and Leff 1975). That said, these

theories have left a tainted legacy that continues to per-

meate the practice and theory of psychiatry, with

researchers treading gingerly around family influences on

mental illness.

H. M. Aldersey (&) School of Rehabilitation Therapy, Queen’s University, 31

George St., Louise D. Acton Building, Kingston, ON K7M 6A8,

Canada

e-mail: [email protected]; [email protected]

R. Whitley

Douglas Mental Health University Institute, 6875 LaSalle

Boulevard, Montreal, QC H4H 1R3, Canada

123

Community Ment Health J (2015) 51:467–476

DOI 10.1007/s10597-014-9783-y

One area of the family that continues to be the object of

some research efforts in psychiatry is the influence of

‘‘expressed emotion’’ on mental illness. Expressed emotion

refers to criticism, hostility, and over involvement

expressed by close kin toward a relative with schizophrenia

(Jenkins 1991). EE reflects a shift ‘‘away from the pre-

vailing psychiatric assumptions concerning the etiological

relevance of psychopathological (i.e., so-called ‘‘schizo-

phrenogenic’’) family features to the identification of

everyday family features that might figure into the course

of major psychiatric disorder’’ (Jenkins 1991, p. 391). This

moved the focus away from investigating families as a risk

factor for onset, instead examining the role families might

play in perpetuating any psychiatric disorder. Indeed, some

research does suggest that families reflecting higher levels

of EE negatively impact the course of psychiatric disorder

(Docherty et al. 2011; Pharoah et al. 2010). Indeed, EE

continues to be a relevant concept among researchers, and

has been used as a measure in other linkages between

family and health. This includes studies of bipolar disorder,

major depression, eating disorders, alcoholism, diabetes,

childhood epilepsy, and myocardial infarction (Leff 2013).

Some parent and family members in the United States

organized themselves into a national movement known as

the National Alliance on Mental Illness (NAMI). This was

partly because they were frustrated with the blame attrib-

uted to families by the psychiatric profession (Harrington

2012). As witnessed by their publicity material, NAMI

advocates a biological basis of severe mental illness,

focusing more on the idea that this is a ‘‘brain disease’’ as

opposed to an illness with a biopsychosocial etiology

(Harrington 2012). Some research suggests that many

families remain invested in the biological model of SMI,

often in a manner which diminishes the family’s role in

aetiology or course of the illness (Callard et al. 2012;

Harrington 2012).

Until relatively recently, families have generally been

under a pathological gaze when examined by psychiatric

researchers. That said, researchers have begun to investi-

gate family as a resource for recovery, with some prom-

ising results. For example, Guarnaccia and Parra (1996)

argue that families often support recovery through the

provision of ‘‘instrumental help’’, which can be funds,

commodities, or logistical assistance to the family member

affected by mental illness. Similarly, Schon et al. (2009)

describe how families can provide practical assistance,

such as taking over chore responsibility, offering tempo-

rary housing, or cooking meals. In their study of recovery

from co-occurring severe mental illness and substance

abuse disorders, EnglandKennedy and Horton (2011) dis-

cuss family support for recovery, including ‘‘intangible

support,’’ or ‘‘emotional, structural, moral, spiritual, or

other interpersonal forms of encouragement’’ (p. 1225).

EnglandKennedy and Horton (2011) also argue that fami-

lies facilitate recovery by being available for their family

member, providing transportation, and voicing encourage-

ment. Topor et al. (2011) note that the simple continued

presence of family members is a form of support for

recovery as it is a ‘‘reminder of what the individual used to

be like and evidence of the fact that there is more to the

person than simply being a psychiatric patient’’ (p. 91).

With an increase in studies reflecting a more balanced

understanding of the family role, researchers have begun

identifying areas where family-related factors can both

facilitate and impede recovery. EnglandKennedy and

Horton (2011) argue that families can impede recovery

when there is a breakdown of trust and communication

between family members and their relation with SMI.

Family members can also negatively affect their relation

with SMI through negative actions and words. Some of

these problems originate from lack of information or mis-

information about mental illness among family members.

Other studies have noted that families can be detrimental to

the recovery process when they remain fixated on a helper

role and are unable to support an individual’s movement

toward autonomy and reciprocal relationships (Bradshaw

et al. 2007; Schon et al. 2009). In a study of individuals

experiencing severe mental illness, substance abuse, and

homelessness, Padgett et al. (2008) found that although

many family members could be a source of warmth and

nurturing, they could also reject and condemn their mem-

bers with mental illness, with their acceptance only con-

tingent on family notions of good behavior. Moreover, they

reported that family relationships could be strained when a

parent or sibling commits a participant for involuntary

treatment. Similarly, Gehart (2012) argues that many

individuals with mental illness are ‘‘estranged from family

and friends because of problems and incidents relating to

their symptoms, and often these support people are not

willing, interested, or available to participate in the

recovery process’’ (p. 452).

Some studies from different cultures have also shown

family to be a protective factor in recovery. Bresnahan

(2003) have argued that family involvement, acceptance

and support of individual members who develop SMI

reduce stress and increase resilience (Bresnahan 2003). A

study at a Nigerian psychiatric hospital found that family

involvement in treatment during hospitalisation was inde-

pendently associated with greater post-discharge appoint-

ment adherence in individuals with SMI (Adeponle et al.

2009).

Evidence suggests that families which are supported and

educated can better enhance their family member’s recovery.

One effective method for supporting and educating families

is the family psychoeducation (FPE) intervention. This is an

evidence-based practice that educates family members and

468 Community Ment Health J (2015) 51:467–476

123

friends about mental illness and how to help someone with a

psychiatric disorder. More than 30 randomized clinical trials

have demonstrated reduced relapse rates, improved patient

recovery, and improved family well-being for people with

SMI participating in FPE (McFarlane et al. 2003; Lincoln

et al. 2007; Lucksted et al. 2012).

In contrast to clinic-based FPE, there are also family-run

interventions to support and educate families that have

members with mental illness. Perhaps the most well-known

family-run model is the National Alliance on Mental Ill-

ness’ (NAMI) Family-to-Family (FTF) program. FTF is a

12-session course that covers a range of topics, including

emotional responses to mental illness, current information

on the major mental illnesses, research on the biology of

mental illness, and information on the evidence-based

practices that are most effective in promoting recovery

(Burland 1998; Lucksted et al. 2012). This information is

delivered to families by family members of an individual

living with mental illness. Research indicates that FTF can

reduce family anxiety, improve family problem-solving,

increase positive coping, and increase family knowledge

(Lucksted et al. 2012). Although the NAMI FTF program

originated in the United States, it is implemented in some

provinces in Canada, including Quebec (ASMFMH 2014).

This brief introduction indicates that the research litera-

ture on family influence on mental illness has evolved from a

solely pathological emphasis towards examination of family

as a resource for recovery. The present study is conducted in

the spirit of this shift in emphasis. The aim of the study is to

assess the perceived influence that family has on recovery

from the perspective of people living with severe mental

illness. Conducted from a position of equipoise, the study

attempts to elicit perceived barriers and facilitators to

recovery related to family, in a grounded qualitative inves-

tigation of people with severe mental illness.

Methods

Participants and Recruitment

54 people (26 women) living with a diagnosis of severe

mental illness were recruited to partake in a semi-struc-

tured interview about recovery. Participants were recruited

from three Montreal psychiatric outpatient clinics. Partic-

ipant inclusion criteria included: (a) must have had a

diagnosis of schizophrenia, major depression, schizoaf-

fective disorder or bi-polar disorder during the last 5 years;

(b) this must have lasted at least 3 years; (c) must currently

be using mental health or rehabilitative services; (d) must

be able to give informed consent; (e) must speak either

English or French; (f) must be 18 years of age or older; and

(g) must not currently be an in-patient.

Procedures

Mental health clinicians identified potential participants

from their clientele who fell into the study inclusion cri-

teria. They then asked the potential participants if they

would consider being involved in a research study on

‘recovery’. The details of those assenting were then passed

on to a member of the research team, who contacted the

person to further explain the study. Clinicians who assisted

in the recruitment of participants were aware of the

inclusion criteria of the study and used medical records and

charts to ascertain diagnosis.

After a researcher completely explained the study to the

participant, the participant was asked if he or she would

like to participate. Those answering in the affirmative gave

written informed consent for their participation. Consent

forms and study protocol were approved by the McGill

University research ethics board prior to the beginning of

the study. All data were de-identified and pseudonyms

were created for each participant. Participants were com-

pensated $20 for their time.

Interviews were conducted at a time and place of par-

ticipants’ choosing between 2011 and 2013. Locations

ranged from the participant’s home, university/hospital

offices, and neutral spaces such as a park or coffee shop.

Participants also chose the preferred language of their

interview (English or French). The aim of interviews was

to elicit individual perspectives on recovery in general.

Questions specifically probed for the role of family in

defining, facilitating, and impeding recovery.

Research assistants were trained in semi-structured

interview techniques, and they conducted the majority of

the interviews. Through the data collection process, the

second author (RW) listened to a sizable portion of the

audio-recordings to give further feedback on interviewing

techniques to the research assistants. In addition to the

semi-structured interview protocol a small socio-demo-

graphics form was used to collect basic demographic data

such as age, gender, marital status and parenthood. The

research assistants were trained to quickly scan demo-

graphic responses in order to integrate them into the course

of the interview—a recommended strategy in qualitative

studies (Maxwell 2005). Interviews typically lasted from

60 to 120 min, with the scope and pace of the interview

controlled by the respondent. For example, there were

pauses and breaks during the interviews, if the participant

so desired. All interviews were audio-recorded and

transcribed.

Analysis

As already noted, the second author (RW) listened to

portions of each interview directly after it occurred for

Community Ment Health J (2015) 51:467–476 469

123

quality control and feedback purposes. The insights gained

from this quality control served as the initial impetus for

the further examination of family as an important aspect of

recovery. Upon completion of data collection, we imported

all interview transcripts into Atlas-ti qualitative data ana-

lysis software. Research assistants initially coded all tran-

scripts for any themes falling under the broad category of

‘‘family’’. The first author (HA) then engaged in open-

coding within the family categorization, marking any

notable sub-themes for further examination. Both authors

then utilized the code manager function in Atlas-ti to

identify codes that occurred most frequently. Both authors

then discussed the open codes in light of code frequencies

and qualitative content of coded data and collectively

distilled the most salient codes into the six themes pre-

sented below. Transcripts were then coded according to

these six themes by the first author.

Results

As noted in the methods section, we recruited 54 people (26

women). Participants fell within four broad ethno-racial

groups: (1) Anglophone Euro-Canadian (n = 10); (2)

Francophone Euro-Canadian (n = 18); (3) Anglophone

African/Caribbean (n = 15); (4) Francophone African/

Caribbean (n = 11). Groups 3 and 4 contained a mixture of

first and second generation immigrants. Participants’ age

ranged from 20 to 69 years with a mean age of 40. 37 par-

ticipants (69 %) were single, 7 participants (13 %) were in a

relationship (dating someone or engaged), 5 participants

(9 %) were married, and 5 participants (9 %) were divorced

or separated. 14 participants (26 %) had children. Interest-

ingly, although the sample of participants was diverse across

age, gender, and ethno-cultural background, we were unable

to identify any discernible patterns specific to any one group

related to family-related variables. Moreover, our data did

not indicate key differences of family as a facilitator or

barrier depending on family member type (e.g., spouse,

sibling, parent); yet this may also be an important topic to

examine in future studies. Rather, the themes given below

were present across all of the participant characteristic

groups, and represent common barriers and facilitators to

recovery, as related to family.

For ease of comprehension, the results are divided into two

separate sections. The first details significant ways in which

family acted as a facilitator to recovery; the second details

ways in which family acted as an impediment to recovery.

Facilitators

Three factors emerged as significant facilitators of recov-

ery, as perceived by participants in this study. We label

these factors (a) moral support; (b) practical support;

(c) family as a motivating factor for recovery.

Moral Support

Moral support from family was manifested in a number of

different ways in the recovery process for participants.

First, respondents remarked that simply having family

‘‘there’’ for them (either physically present or otherwise in

communication) was a positive influence on recovery.

Family presence enabled participants to understand that

they are not alone in their recovery efforts and that there

are other people that care about them. This family presence

appeared to provide the constancy and stability that many

respondents reported as necessary for recovery. Partici-

pants cited the importance of being able to trust and confide

in their family members throughout the recovery process.

Respondents often characterized their family members as

‘‘loving’’ and ‘‘supportive’’. In the context of social support

from families, many echoed Justine, a 20-year old fran-

cophone Euro-Canadian who said ‘‘if something happens,

they’re always gonna be there.’’

More tangibly, participants cited visits and phone calls

from family in the hospital and in their homes as important

forms of support. Interestingly, telephone conversations

and visits were perceived to be of benefit to recovery by not

addressing issues surrounding mental illness. Rather, con-

versations or mutual exchanges about everyday life helped

many consumers feel ‘‘normal’’ or forget about their ill-

ness. As Alice, a 34-year old Anglophone African/Carib-

bean, remarked:

I think definitely the support from friends and family

helps a lot. When you get visitors, phone calls, like

that is one thing for myself; typically when I am get-

ting a lot better. I just spend time on the phone in the

hospital; I literally sit down in the booth for like hours

just talking on the phone because communication with

the outside world, knowing that I have friends and

family that care. Even if they can’t come and visit, but

just doing what I would do at home; talking on the

phone. Just communicating, knowing what is going on

in their lives, they know what I am doing. That support

and just knowing that you have people that support

you and care about you and love you. That helps a lot.

Oftentimes, participants, like John, a 41-year old

Anglophone African–Caribbean, noted that in addition to

visiting their member in the hospital, family members can

assist recovery by getting their relation out of the house and

better connected with the local community:

My brother he take me out the other night, he take me

out and buy me a beer, so next time I say I wanna go

470 Community Ment Health J (2015) 51:467–476

123

downtown, and play pool, just to be interactive with

people make me feel alive again, not like a crazy

person.

The data indicate that family can further provide social

support for recovery through the rationalization or nor-

malization of mental illness. Respondents argued that

family members have helped them to put mental illness in

perspective, to see it as any other type of health problem.

Family members played an important role in helping par-

ticipants understand aspects of their mental illness, often-

times discussing family history to provide insight about

potential genetic factors of mental illness. Many respon-

dents noted their own surprise that their family members

accepted the diagnosis of mental illness and either under-

stood or made efforts to understand the mental illness and

its appropriate treatment. As Jennifer, 48-year old Anglo-

phone Euro-Canadian noted:

You have to accept it, and you have to be happy. I

could’ve had a house, I could’ve worked, but my

mother-in-law said to me, ‘‘be happy with what you

have’’ because I worked before, I worked for ten

years, so I was able to get a little pension that I’m

supposed to have to help my family. […] A lot of people are sick; it’s not your fault she said.

Finally, further support from families is evidenced

through the encouragement of consumers to continue with

their treatment. This could be by advising the family

member to continue taking his or her medication, telling

him or her to continue attending psychiatric appointments

or sessions at rehabilitation centers, or encouraging him or

her to abstain from alcohol, drugs, or unhealthy

relationships.

Practical Support

Although moral support was the most pervasive type of

support provided by family that was cited in this study,

many participants also highlighted practical support from

family as key to their recovery. Family often provides

practical support in the form of resources for participants

during their recovery. Financial support came through the

provision of housing, paying a separate rent for the indi-

vidual, providing meals, giving pocket money, or buying

the individual gifts. Financial assistance is often an

important facilitator to recovery, given that many respon-

dents were unable to obtain or hold a job. Michel, a 40-year

old Francophone African–Caribbean notes that his family

‘‘always take me out to eat. […] They bought me things. They bought me presents. They have really helped me.’’

In addition to financial support, respondents noted that

family provides other forms of practical support to aid in

their recovery. This can be anything from providing

transportation to the store or to doctor’s appointments to

helping the individual fill out forms or get registered in

school programs. Participants also discussed when family

members would take over their familial responsibilities and

household chores during periods of illness when they were

unable to do them. Adam, a 35-year old Anglophone

African–Caribbean remarked: ‘‘They’ll make sure that I

have the support—the medical support—that my bills are

paid, that my dog is taken care of, that if I need anything –

well, everything. They do everything.’’

Family as a Motivation for Recovery

The data indicate that the mere presence of family can

often influence recovery without explicit effort. Specifi-

cally, participants cited family as an intrinsic motivator

behind their efforts toward recovery. In some cases,

respondents like Peter, a 41-year old Anglophone African–

Caribbean, focused on recovery because they saw this as a

path to having a family in the future.

It took me time because I don’t want to marry

somebody that will say ‘I don’t really know that I

married a sick person,’ do you understand because

when I get sick, will that person really care for me?

And will they say, ha, this guy. …Maybe one time I will go off, that is if I am kind of sick. So it took me

time… But getting married…It excites me, it mean I want to have kids; I want to make family.

Results related to family as a motivator for recovery show

that participants were not cynical about families and indeed

saw the creation or maintenance of family as an important

component of individual recovery. For example, some

respondents aspired to having a spouse and/or children and

believed that this would be the ultimate marker that they

were in recovery. For others, like Joe, a 45-year old Anglo-

phone African/Caribbean, it was the desire to provide for

their existing family that motivated them to recovery.

I am teaching them not to give up; you fight, fight, fight

and fight. Until you can’t fight anymore. Oh yeah, I

have a reason to keep going: it is my kids. … And when they see me struggle, some days I struggle to go to

work, to do that. I do it and then come back home. And

they know how hard it is for me, but when I see their

face and they smile, it helps me. Like I just didn’t give

up and say ok, fine I quit. No, I keep going. So, no, you

need that. My motivation, you asked me that before, is

my kids.

Participants in this study clearly showed that just as

parents can have an influence on their children’s health and

wellbeing; children can also have an influence the health

Community Ment Health J (2015) 51:467–476 471

123

and wellbeing of the adults in their family. Francine, a

61-year old Anglophone African–Caribbean told us about

her ultimate motivator for recovery:

I have a grandson, and my grandson is four years old.

And I would like to know him more and do things for

him and with him; you never know what can happen in

life. You know, maybe his mother might get sick and

never know what can happen. I want to be able to be

there for him. So I want to keep myself healthy, so I

am available if a problem arises and boom: there I am.

For still others, like Luke, a 37-year old Anglophone Euro-

Canadian, recovery was a way to reconnect with family whom

they had hurt during their experience with mental illness.

I’d spend my days and nights drinking and smoking

weed and cigarettes and getting into trouble and not

having a very good relationship with my family and

friends and it was the wrong path. It’s the opposite of

the path that I’ve been taking now. Making amends

with family and friends and trying to be there for

them and trying to stay out of trouble and be pro-

ductive is just so much more important than it ever

was before because I wasted so much time.

Barriers

Three factors emerged from the data as significant barriers

to recovery. Barriers exist when family (a) acts as a

stressor; (b) displays stigma and lack of understanding; or

(c) forces hospitalization.

Family as a Source of Stress

The results indicate that stress from family can come from

both intentional actions or from less intentional stressors.

Participants noted numerous common sources of stress. These

include family members being judgemental, making the

individual feel weak or incapable, or speaking to the family

member as if he or she is a child. Participants noted that they

became stressed when family members saw different life

paths for them, pushing them in directions they did not want to

go, particularly as it relates to education, career, marriage, or

children. Similarly, participants reported stress when family

membersdisagreedwitheverydaychoices,forexample eating

or dressing habits. Divorce and other family conflicts were

also seen as stressful and an impediment to recovery. Some

participants reported that their recovery gathered pace when

family members moved out. Marie, a 58-year old Franco-

phone Euro-Canadian stated:

I got sick again after, because my sons came back to

the house and that went very bad. It caused me to get

sick again. […] Then, at a given moment, I was capable of saying to my son, ‘‘I will give you X many

months to find an apartment.’’ So, to find solutions to

the problems I was facing. Then, when he left for his

own apartment… he started doing better, and me as well. This was a something that really helped me.

Participants were influenced by the illness, suicide, or

accidental death of family members, or the feeling of

responsibility to provide and care for family members.

Claire, a 42-year old Anglophone African–Caribbean,

demonstrates an important theme: Family is important, but

family responsibility can also become overwhelming.

I would like more independence. It is not really

preventing recovery, but I would like more indepen-

dence but I am torn between like familial obligations

cause my brother just went through a separation. My

mother’s health isn’t the greatest. No I have a feeling

like that they need me around, even though suppos-

edly I am not all there or whatever that they think, if

they need me. You know, I don’t want to desert them.

[…]You know, it is my family.

Many participants reduced contact with stressful family

members. However most participants (like Claire above)

accepted family members as important components in their

lives and did not see lessening responsibility or reducing

contact with family as a viable option to facilitate recovery.

Stigma and Lack of Understanding

Some participants like Francine, a 61-year old Anglophone

African–Caribbean, noted that within their family they felt

stigmatized because of their mental illness and that this was

a barrier to recovery.

Now there is a big stigma of mental illness when you

don’t know about it. When you don’t know about it, it

is the end of the world for certain members of the

family. And my daughter falls into that category. She

has not educated herself in my illness. And she views

it like a plague; like she gets too close to it she is going

to get it. … She avoids me because she doesn’t want to be associated with me. She thinks it is bad and she

doesn’t want people to know that her mother is sick. If

she has a friend, if her friends see her with me, she

doesn’t want. She is ashamed if I would react in a way

that would not be normal to her. … So when she sees me, she sees me in areas that are very remote; very,

very, places where her friends wouldn’t come to.

Because of the stigma associated with mental illness,

participants reported that family members would be

ashamed of their member in recovery, would deny that

472 Community Ment Health J (2015) 51:467–476

123

member actually had a mental illness, and would try to hide

the mental illness from the extended family or the wider

community for fear of a ruined family reputation. Some

participants noted that stigma may also have a cultural

basis for them, as they experienced stigma among family in

their community of origin (e.g. Haiti) more than in Canada.

Participants noted that they experienced barriers to recovery

when their family did not understand or did not make efforts to

understand their experience with mental illness. Family would

deny that an individual had mental illness or would not believe

that mental illness was the reason behind an individual’s

behavior. One participant noted that her father insisted that she

was just ‘‘making it all up’’. Sometimes, participants reported

that their family members would understand neither the etiol-

ogy of the individual’s specific diagnosis nor the individual’s

experience with the diagnosis and treatment. Anne, a 34-year

old Anglophone African/Caribbean, notes.

Like I invited my dad more than once to come to a

doctor’s appointment with me and he is always late and

this and that. So he never made it. And it would be nice

if my family could be more informative. Like get

themselves informed, find out what the causes are of

bipolarism, like how to deal with it. Like come, attend a

workshop or whatever. Read stuff. Like I had my

cousin, he was really helpful. And he still is. He went

online and he read up about it. And he informed him-

self. Like do stuff like that. Don’t just think it is because

I am not taking my medication and that is where it all

starts. And that is where it all ends. That is not it. Inform

yourself and find out about the illness. See what causes

it. See what cannot cause it and stuff like that and how

you can help and how you can be supportive. And stop

just passing the buck and thinking oh, it is because of

your friends, oh it is because of whatever, past rela-

tionships. It is not, and don’t take the blame on for

yourselves, too. Because family stress also adds to it.

As indicated above, participants noted a need for increased

family education about mental illness and how to best

support the family member in his or her recovery. Although

many participants noted a lack of understanding from

family members, many others noted how their family truly

made efforts to understand the mental illness by talking to

doctors or looking things up on the internet. Others noted

that their family members, to their surprise, did actually

understand mental illness and this facilitated recovery.

Family Forcing Hospitalization

This is the theme which was the most difficult to classify as

a facilitator or a barrier. Participants were quite divided

about whether forcing hospitalization was a barrier or a

facilitator, though many saw it more as a barrier. The data

indicated that family members often play a key role in

detecting mental illness symptom onset and/or initiating

treatment. Participants that were forcibly or voluntarily

hospitalized often noted that it was their family that either

called the police or ambulance or drove the individual to

the hospital to have them admitted. When it was considered

a barrier to recovery, participants like George, a 40-year

old Francophone African/Caribbean, believed that they had

been unjustly hospitalized.

I had an altercation with my two sisters and they

conspired against me. They signed a paper that forced

me to go back to the hospital. Just for a small dis-

cussion about nothing. It’s my sisters who made me

return to the hospital under a false motive.

Some participants admitted that they were more likely to talk

to friends about their mental illness than their family as they

feared that the family would rush to have them hospitalized,

rather than just listen to them. Participants often indicated

feeling a sense of betrayal when family members initiate

treatment. This sentiment is well expressed by Anne below, a

34-year old Anglophone African–Caribbean.

And my dad like dragged me back there one time. I

went with my dad and my friend and my friend

promised me that no, we are not going admit you

back. And my dad is like ‘yeah, we are not.’ And then

you are waiting in the waiting room and it was taking

so long. And he went behind my back and he went in

and he asked, he commanded to see my doctor. And

she came out and he came out and they both dragged

me basically like on my butt saying ‘oh you are not

taking your meds, you are not taking your meds and

all.’ And it is just like yes I am. They put me back in

and they increased the dosage.

As we note above, although more respondents noted forced

hospitalization as a barrier, other individuals were grateful

to their family for taking them to hospital when in crisis.

Jean-Claude, a 25-year old Francophone African/Carib-

bean, felt that such a hospitalization was a pivotal and

positive force in his recovery.

They brought me to the hospital because when my

father saw that I wasn’t leaving my room, and

because I was keeping my distance from everyone,

and because I hardly ever spoke. I wanted to flee, and

I had just taken my things and ran outside. My father

ran behind me, excuse me to say this, but he was in

his boxers in the winter. He ran behind me. After,

when he brought me back to the house, I became

aggressive. Then, after that he was a little scared so

he had no choice but to call the police or the

Community Ment Health J (2015) 51:467–476 473

123

ambulance. Then the police came and they brought

me to the hospital. It was that day that my recovery

began.

Discussion

These findings demonstrated that family can be a facilitator

of recovery by providing moral support, practical support,

and by serving as an intrinsic motivation for recovery. Far

from being cynical about family, most respondents in this

study truly loved and appreciated having family in their

lives and considered this as an essential aspect of recovery.

Yet, family could also be a barrier through stress, stigma,

and lack of understanding. Many participants reported that

forced hospitalizations initiated by a family member were

inimical to recovery, though others saw this as a positive

nodal point in their recovery journey.

Participants in our study reported that criticism or over-

involvement from family members increased their stress

and worked against recovery. Contrariwise, warmth and

positive regard from family members was considered as a

facilitator of well-being. These findings are somewhat

consistent with the extant literature on expressed emotion,

indicating that emotional expression within families can

indeed have an impact on recovery (Wearden et al. 2000).

However expressed emotion theory is insufficient in

explaining the complete findings from this study. We

identified numerous facilitators to recovery unrelated to

emotional expression, for example practical and instru-

mental support. As such, our results caution against an

overreliance on theories of expressed emotion in explain-

ing the relationship between family dynamics and

recovery.

Findings around family as a barrier indicated that

recovery-oriented concepts such as autonomy and agency

can be complicated by family ties and family norms of

reciprocity and duty. Likewise, some of the participants’

reports of paternalistic and infantilizing family perspec-

tives indicated that some families may still possess out-

dated notions of mental illness, believing in the limited

capacity of the consumer to lead a self-directed life.

This demonstrated the ongoing need and desire for

improved mental health literacy among family members.

To date, families have gained knowledge of mental illness

through various arenas, including interventions such as

family psychoeducation and NAMI’s peer-led Family to

Family program. These interventions have been shown to

be effective in increasing knowledge and improving

mental health literacy (McFarlane et al. 2003; Lincoln

et al. 2007; Lucksted et al. 2012). However critics of

family interventions argue that they are often prescriptive,

with some commentators noting that the ‘‘content of many

of the most empirically validated family interventions

were designed in the 1970 s and 1980 s and embrace

more of a ‘successful management of a chronic illness’

theme rather than a recovery orientation’’ (Glynn et al.

2006, p. 455). Our findings, especially those regarding the

importance of autonomy and agency, support the con-

tention that family interventions must ‘‘consistently reflect

the mental health recovery paradigm to ensure that the

intervention…address consumers’ and family members’ real-life concerns and aspirations’’ (Lucksted et al. 2012,

p. 112).

Our results indicated the importance of listening and

honoring consumer preferences about family involvement

in recovery, rather than assuming that family is either a

universally positive or negative force. This finding con-

verges with other studies showing that most people with

severe mental illness desire some sort of family involve-

ment, though a substantial minority do not (Cohen et al.

2013). When revising family interventions to better reflect

a recovery orientation, it might be appropriate to put an

even greater emphasis on the importance of consumer

choice and agency regarding the involvement of family.

Revised or novel interventions should include ways to

assess how exactly consumers want their families to be

involved in their recovery (if at all).

Our data also suggest that family interventions might

better emphasize the importance of mutuality in relation-

ships, highlighting the importance of contribution rather

than just receiving aid in family relationships. Indeed, in

one study, families that ‘‘emphasized the importance of

giving rather than just receiving were related to increased

optimism about recovery as well as increased self-confi-

dence and self-esteem’’ (Pernice-Duca 2010, p. 22).

Although we argue here that family has the potential to

greatly impact individual recovery efforts, it is also

important to note that an individual’s recovery may, in

turn, have great impact on the family. This can lessen

family stress and caregiver burden (Lefley 1997) and

enable the individual in recovery to contribute to overall

family economics, wellbeing, and quality of life.

Consumer agency is also important in determining the

most appropriate role for family involvement, given that

our results demonstrated that the very same family of a

consumer can function as both a protective and a risk factor

for recovery. Related future research might examine how a

provider, a consumer, and/or a family member could

identify what is helpful or harmful within the family sys-

tem. Emerging patterns will likely vary depending on

individual-level factors, such as family characteristics or

severity of illness and will in turn lead to new research

questions that further research could examine. Finally, our

data did not indicate key differences of family as a facili-

tator or barrier depending on family member type (e.g.,

474 Community Ment Health J (2015) 51:467–476

123

spouse, sibling, parent); yet this may also be an important

topic to examine in future studies.

Limitations of the Study

This study has numerous limitations. First, we did not

complement our interviews with observational methods

examining in situ interactions of participants with their

family members. Additional observational methods would

have allowed us to triangulate data to corroborate patient

perspectives. Second, this study was conducted solely from

the point of view of the consumers of mental health ser-

vices. Thus, the findings presented in this article represent

the viewpoint of one subset of the family. Further studies

would be wise to interview both consumers and other

family members in order to get a more balanced view of

the role of family in the recovery process. Indeed, families

may have very different perspectives on the facilitators and

barriers that they may present in the recovery process, and

this is an equally important perspective that we must take

into consideration when evaluating and improving family

and consumer interventions for recovery. Finally, we did

not sample individuals based on experience of family

interventions. Indeed none of the participants reported

being involved in any form of family intervention. Further

research may need to assess how far such interventions are

consistent with the recovery model and related concepts

such as agency, autonomy and choice. In spite of these

limitations, we believe that this study provides useful

insight about the role of family in the recovery process.

Conclusion

In conclusion, this article described family as a crucial

component of recovery from severe mental illness. With

this research, we strive to contribute to the ongoing shift in

pathological-modeled research to focus on more positive,

solutions-based scholarship, looking at how to build upon

naturally-existing resources to facilitate recovery from

severe mental illness. Our data indicate that family can

provide important moral and practical support and can

serve as a motivating force for recovery. But the data also

indicate that family members can be a source of stress, lack

understanding, and force their member with mental illness

into the hospital against his or her will. We hope that this

knowledge will be useful to clinicians working with

patients and families, ultimately enhancing recovery and

well-being for people with severe mental illness.

Acknowledgments We would like to express appreciation to the clinicians and consumers whose participation made this study possi-

ble. We also gratefully acknowledge Marie-Eve Boucher, Anna

Miller, and Aldric Reid for their work as research assistants on this

project. We would like to thank the Canadian Institutes of Health

Research who funded this research through an Open Operating Grant

(231520).

References

Adeponle, A. B., Thombs, B. D., Adelekan, M. L., & Kirmayer, L.

(2009). Family participation in treatment, post-discharge

appointment and medication adherence at a Nigerian psychiatric

hospital. British Journal of Psychiatry, 194, 86–87. doi:10.1192/

bjp.bp.108.052217.

ASMFMH. (2014). About Les Amis de la Santé Mentale. Retrieved

from http://www.asmfmh.org/?page_id=506. Accessed on Janu-

ary 28, 2014.

Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. (1956).

Toward a theory of schizophrenia. Behavioral Science, 1(4),

251–254.

Becker, D. R., & Drake, R. E. (2003). A working life for people with

severe mental illness. Oxford: Oxford University Press.

Bradshaw, W., Armour, M. P., & Roseborough, D. (2007). Finding a

place in the world: The experience of recovery from severe

mental illness. Qualitative Social Work, 6, 27–47.

Bresnahan, M. (2003). Geographical variation in incidence, course,

and outcome of schizophrenia: A comparison of developing and

developed countries. In R. Murray, P. Jones, E. Susser, J. Os, M.

Cannon, et al. (Eds.), The epidemiology of schizophrenia.

Cambridge: Cambridge University Press.

Burland, J. (1998). Family-to-family: A trauma and recovery model

of family education. New Directions for Mental Health Services,

77, 33–41.

Callard, F., Rose, D., Hanif, E. L., Quigley, J., Greenwood, K., &

Wykes, T. (2012). Holding blame at bay? 0Gene talk0 in family members’ accounts of schizophrenia aetiology. BioSocieties, 7,

273–293.

Cohen, A. N., Drapalski, A. L., Glynn, S. M., Medoff, D., Fang, L. J.,

& Dixon, L. B. (2013). Preferences for family involvement in

care among consumers with serious mental illness. Psychiatric

Services, 64(3), 257–263.

Docherty, N. M., St-Hilaire, A., Aakre, J. M., Seghers, J. P.,

McCleery, A., & Divilbiss, M. (2011). Anxiety interacts with

expressed emotion criticism in the prediction of psychotic

symptom exacerbation. Schizophrenia Bulletin, 37(3), 611–618.

EnglandKennedy, E. S., & Horton, S. (2011). ‘‘Everything that I

thought that they would be, they weren’t:’’ Family systems as

support and impediment to recovery. Social Science and

Medicine, 73, 1222–1229.

Gehart, D. R. (2012). The mental health recovery movement and

family therapy, part II: A collaborative, appreciative approach

for supporting mental health recovery. Journal of Marital &

Family Therapy, 38(3), 443–457.

Glynn, S. M., Cohen, A. N., Dixon, L. B., & Niv, N. (2006). The

potential impact of the recovery movement on family interven-

tions for schizophrenia: Opportunities and obstacles. Schizo-

phrenia Bulletin, 32(3), 451–463.

Guarnaccia, P. J. (1998). Multicultural experiences of family

caregiving: A study of African American, European American,

and Hispanic American families. In H. Lefley (Ed.), Families

Coping with Mental Illness: The cultural context. San Francisco:

Jossey-Bass Publishers.

Guarnaccia, P. J., & Parra, P. (1996). Ethnicity, social status, and

families’ experiences of caring for a mentally ill family member.

Community Mental Health Journal, 32, 243–260.

Community Ment Health J (2015) 51:467–476 475

123

Harrington, A. (2012). The art of medicine, the fall of the

schizophrenogenic mother. The Lancet, 379, 1292–1293.

Hirsch, R., & Leff, J. P. (1975). Abnormalities in the parents of

schizophrenics: A review of the literature and an investigation of

communication defects and deviances. New York: Oxford

University Press.

Jenkins, J. H. (1991). Anthropology, expressed emotion, and schizo-

phrenia. Ethos, 19, 387–431.

Laing, R. D. (1967). The Politics of Experience. Harmondsworth:

Penguin.

Leff, J. (2013). Expressed emotion in 100 words. The British Journal

of Psychiatry, 202, 335.

Lefley, H. P. (1997). The consumer recovery vision: Will it alleviate

family burden? American Journal of Orthopsychiatry, 67(2),

210–219.

Lincoln, T. M., Wilhelm, K., & Nestoriuc, Y. (2007). Effectiveness of

psychoeducation for relapse, symptoms, knowledge, adherence,

and functioning in psychotic disorders: A meta-analysis. Schizo-

phrenia Research, 96, 232–245.

Lucksted, A., Mcfarlane, W., Downing, D., Dixon, L., & Adams, C.

(2012). Recent developments in family psychoeducation as an

evidence-based practice. Journal of Marital and Family Ther-

apy, 38(1), 101–121.

Luhrmann, T. M. (2007). Social defeat and the culture of chronicity:

Or, why schizophrenia does so well over there and so badly here.

Culture, Medicine and Psychiatry, 31, 135–172.

Maxwell, J. A. (2005). Qualitative research design: An interactive

approach. New York: Sage.

McFarlane, W. R., Dixon, L., Lukens, E., & Lucksted, A. (2003).

Family psychoeducation and schizophrenia: A review of the

literature. Journal of Marital and Family Therapy, 29(2), 223–245.

Mental Health Commission of Canada. (2012). Changing directions,

changing lives: The mental health strategy for Canada. Calgary,

AB: National Library of Canada. Retrieved December 4, 2014

from http://strategy.mentalhealthcommission.ca/pdf/strategy-text-

en.pdf.

Neill, J. (1990). Whatever became of the schizophrenogenic mother?

American Journal of Psychotherapy, 44(4), 499–505.

Padgett, D. K. (2007). There’s no place like (a) home: Ontological

security among persons with serious mental illness in the United

States. Social Science and Medicine, 64(9), 1925–1936.

Padgett, D. K., Henwood, B., Abrams, C., & Drake, R. E. (2008).

Social relationships among persons who have experienced

serious mental illness, substance abuse, and homelessness:

Implications for recovery. American Journal of Orthopsychiatry,

78(3), 333–339.

Pernice-Duca, F. (2010). Family network support and mental health

recovery. Journal of Marital and Family Therapy, 36(1),

13–257.

Pharoah, F., Mari, J. J., Rathbone, J., Wong, W. (2010). Family

intervention for schizophrenia. Cochrane Database of Systematic

Reviews, 12, CD000088. doi:10.1002/14651858.CD000088.pub3.

Schon, U., Denhov, A., & Topor, A. (2009). Social relationships as a

decisive factor in recovering from severe mental illness. Inter-

national Journal of Social Psychiatry, 55(4), 336–347.

Topor, A., Borg, M., Di Girolamo, S., & Davidson, L. (2011). Not

just an individual journey: Social aspects of recovery.

International Journal of Social Psychiatry, 57(1), 90–99.

Ware, N. C., Hopper, K., Tugenberg, T., Dickey, B., & Fisher, D.

(2007). Connectedness and citizenship: Redefining social inte-

gration. Psychiatric Services, 58(4), 469–474.

Wearden, A. J., Tarrier, N., Barrowclough, C., Zastowny, T. R., &

Rahill, A. A. (2000). A review of expressed emotion research in

health care. Clinical Psychology Review, 20, 633–666.

Whitley, R., & Drake, R. (2010). Recovery: A dimensional approach.

Psychiatric Services, 61, 1248–1250.

476 Community Ment Health J (2015) 51:467–476

123

Copyright of Community Mental Health Journal is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.