Relationship Quality Among Persons with Serious Mental Illness and Their Relatives: Rates and Correlates.

Supportive family relationships for persons with serious mental illness (SMI) are correlated with positive functional, health and mental health outcomes and are essential to the recovery process. However, there has been a dearth of research on positive family dynamics. Using multivariate logistic regression with a U.S. community-recruited sample of persons with SMI (N = 523), we examined the extent to which demographics, clinical characteristics, and supportive and problematic relationship interactions were associated with relationship quality with reference relatives (RR). Secondarily, we tested whether the relationship between routine limit-setting practices by RR toward participants and relationship quality was significantly mediated by perceived emotional overinvolvement using Baron and Kenny's four step method. High levels of relationship quality were reported by two-thirds of the sample. Relationship quality was positively associated with frequency of contact between participants and RR, participants helping RR with activities of daily living, and caregiving provided by RR to participants. High relationship quality was negatively associated with RR being parents or other family members (compared to romantic partners), perceived emotional overinvolvement of RR, and psychological abuse by RR toward participants. Clinical and demographic characteristics were not associated with relationship quality. Perceived emotional overinvolvement was found to be a mediator between routine limit-setting practices and relationship quality. These results can help direct clinicians in targeting factors that will likely enhance the process of recovery.

Recipients of Representative Payeeship with Mental Illness: Financial Leverage, Conflict, and Satisfaction.

This study aimed to examine self-report of financial leverage, conflict, and satisfaction pertaining to representative payeeship for persons with mental illness, which research has not examined in the past decade. Sixty representative payee recipients with mental illness residing across the U.S. completed an online survey, with most (n = 50) receiving representative payeeship by family members/friends. Wilcoxon-Mann-Whitney tests and Spearman correlations were computed. One-third of participants reported experiencing financial leverage and conflict "sometimes" or more often and were dissatisfied with their representative payee arrangement. With the exception of use of alcohol and/or drugs, no participant characteristic was associated with financial leverage, conflict, or satisfaction. Financial leverage was reported to be greater when representative payees were family members/friends. Financial leverage and conflict were positively associated with each other and negatively associated with satisfaction. It is advisable that satisfaction with representative payeeship be increased and conflict resulting from representative payeeship be minimized.

Involvement of Guns in Nonfatal Conflict Between Adult Children and Their Parents.

The objectives of the present analyses are to examine the frequency, nature, and correlates of nonfatal gun use in incidents of conflict between adult children and their parents, to which police were summoned. A cross-sectional study design was used with all cases of domestic violence to which police were called between adult children and their parents, in Philadelphia, PA, in 2013 (N = 6,248). Data were drawn from forms required to be completed by police when responding to domestic violence calls for assistance. A series of multivariate logistic regression models were estimated. Of the 6,248 incidents, 5,486 involved no weapon, 522 involved a bodily weapon, 190 involved a non-gun external weapon, and 50 involved a gun. Guns were most often used to threaten victims (66%), with guns less often fired (6%) or used to pistol whip victims (4%). Compared to incidents involving a bodily weapon, when guns were involved, offenders were less likely to have pushed, grabbed, or punched the victim and victims were less likely to have visible injuries; however, offenders were more likely to have threatened victims and victims were more likely to be observed as frightened. Police officers intervened similarly to incidents involving guns vs. bodily weapons. This is the first study we are aware of to focus on nonfatal gun use between family members who are not intimate partners, with the results extending much of what is known regarding nonfatal gun use among intimate partners to nonfatal gun use among adult children and parents.

Functional Family Therapy for families of youth (age 11-18) with behaviour problems: A systematic review and meta-analysis.

Background: Functional Family Therapy (FFT) is a short-term family-based intervention for youth with behaviour problems. FFT has been widely implemented in the USA and other high-income countries. It is often described as an evidence-based program with consistent, positive effects. Objectives: We aimed to synthesise the best available data to assess the effectiveness of FFT for families of youth with behaviour problems. Search Methods: Searches were performed in 2013-2014 and August 2020. We searched 22 bibliographic databases (including PsycINFO, ERIC, MEDLINE, Science Direct, Sociological Abstracts, Social Services Abstracts, World CAT dissertations and theses, and the Web of Science Core Collection), as well as government policy databanks and professional websites. Reference lists of articles were examined, and experts were contacted to search for missing information. Selection Criteria: We included randomised controlled trials (RCTs) and quasi-experimental designs (QEDs) with parallel cohorts and statistical controls for between-group differences at baseline. Participants were families of young people aged 11-18 with behaviour problems. FFT programmes were compared with usual services, alternative treatment, and no treatment. There were no publication, geographic, or language restrictions. Data Collection and Analysis: Two reviewers independently screened 1039 titles and abstracts, read all available study reports, assessed study eligibility, and extracted data onto structured electronic forms. We assessed risks of bias (ROB) using modified versions of the Cochrane ROB tool and the What Works Clearinghouse standards. Where possible, we used random effects models with inverse variance weights to pool results across studies. We used odds ratios for dichotomous outcomes and standardised mean differences for continuous outcomes. We used Hedges g to adjust for small sample sizes. We assessed the heterogeneity of effects with χ 2 and I 2. We produced separate forest plots for conceptually distinct outcomes and for different endpoints (<9, 9-14, 15-23, and 24-42 months after referral). We grouped studies by study design (RCT or QED), and then assessed differences between these two subgroups of studies with χ 2 tests. We generated robust variance estimates, using correlated effects (CE) models with small sample corrections to synthesise all available outcome data. Exploratory CE analyses assessed potential moderators of effects within these domains. We used GRADE guidelines to assess the certainty of evidence on six primary outcomes at 1 year after referral. Main Results: Twenty studies (14 RCTs and 6 QEDs) met our inclusion criteria. Fifteen of these studies provided some valid data for meta-analysis; these studies included 10,980 families in relevant FFT and comparison groups. All included studies had high risks of bias on at least one indicator. Half of the studies had high risks of bias on baseline equivalence, support for intent-to-treat analysis, selective reporting, and conflicts of interest. Fifteen studies had incomplete reporting of outcomes and endpoints. Using the GRADE rubric, we found that the certainty of evidence for FFT was very low for all of our primary outcomes. Using pairwise meta-analysis, we found no evidence of effects of FFT compared with other active treatments on any primary or secondary outcomes. Primary outcomes were: recidivism, out-of-home placement, internalising behaviour problems, external behaviour problems, self-reported delinquency, and drug or alcohol use. Secondary outcomes were: peer relations and prosocial behaviour, youth self esteem, parent symptoms and behaviour, family functioning, school attendance, and school performance. There were few studies in the pairwise meta-analysis (k < 7) and little heterogeneity of effects across studies in most of these analyses. There were few differences between effect estimates obtained in RCTs versus QEDs. More comprehensive CE models showed positive results of FFT in some domains and negative results in others, but these effects were small (standardised mean difference [SMD] <|0.20|) and not significantly different from no effect with one exception: Two studies found positive effects of FFT on youth substance abuse and two studies found null results in this domain, and the overall effect estimate for this outcome was statistically different from zero. Over all outcomes (15 studies and 293 effect sizes), small positive effects were detected (SMD = 0.19, SE = 0.09), but these were not significantly different from zero effect. Prediction intervals showed that future FFT evaluations are likely to produce a wide range of results, including moderate negative effects and strong positive results (-0.37 to 0.75). Authors' Conclusions: Results of 10 RCTs and five QEDs show that FFT does not produce consistent benefits or harms for youth with behavioural problems and their families. The positive or negative direction of results is inconsistent within and across studies. Most outcomes are not fully reported, the quality of available evidence is suboptimal, and the certainty of this evidence is very low. Overall estimates of effects of FFT may be inflated, due to selective reporting and publication biases.

Community Behavioral Health Service Use and Criminal Recidivism of People With Mental, Substance Use, and Co-occurring Disorders.

OBJECTIVE: This study assessed the relationship between community behavioral health service (CBHS) use and criminal recidivism in a broad sample of potential beneficiaries and by diagnostic group. METHODS: Among a cohort of people on probation with any mental and/or substance use disorder (N=772), the study estimated the effect of CBHS use on rearrest with Cox proportional hazards models. RESULTS: Service use significantly predicted reduced recidivism among people with any mental disorder (hazard rate=0.36, p=0.008), but not among those with any substance use disorder or co-occurring disorders. CONCLUSIONS: CBHS use in a given week predicted a 64% reduced recidivism risk during the following week among people with any mental disorder. However, CBHS use had no clear relationship with recidivism among people with co-occurring disorders or any substance use disorder. CBHS use may reduce recidivism, depending on recipient and service characteristics.

Family Conflict and Violence by Persons with Serious Mental Illness: How Clinicians Can Intervene During the COVID-19 Pandemic and Beyond.

Although most persons living with serious mental illness (SMI) do not act violently, this population is at a modestly increased risk of engaging in violence, with family members being the most common victims. Consequently, evidence suggests that a sizable minority of family members-many of whom are caregivers-have experienced violence by their relative with SMI. The risk of conflict and violence in families of persons with SMI is likely currently heightened due to a range of challenges resulting from the COVID-19 pandemic (e.g., interruption in treatment services and the occurrence of arguments while sheltering in place together). As such, during the pandemic, it is particularly important that clinicians intervene with these populations to prevent conflict and violence and strengthen their relationships with each other. Based on available evidence, we recommend that clinical interventions aiming to do so address the following topics with family members and/or persons with SMI: mutual understanding; positive communication; effective problem-solving; symptoms and psychiatric crises; triggers to, and early warning signs of, anger and conflict; and strategies for de-escalating conflict and managing violent behavior. We offer suggestions for how clinicians can address these topics and recommend established clinical resources providing more guidance in this area.

Serious mental illness and incidents between adult children and parents responded to by police.

BACKGROUND: Despite a sizable minority of persons with serious mental illness (SMI) acting aggressively toward family members, little is known about this topic. The objectives of the present analyses are to examine the association of offenders' SMI status with offender behaviors and victim outcomes and to compare the immediate contextual characteristics of incidents involving offenders with and without SMI. METHODS: Using a cross-sectional design, all incidents of domestic violence to which police were called between adult children and their parents in Philadelphia, PA, in 2013 (N = 6191) were analyzed. Additionally, incidents in which the offender was indicated to have SMI (n = 327) were matched with a sample of incidents in which the offender was not indicated to have SMI (n = 327). RESULTS: Offenders having SMI was not associated with using a bodily weapon or gun, threatening victims, or damaging property. Offenders having SMI was associated with a decreased risk of offenders using a non-gun external weapon and victims being observed to have a complaint of pain or visible injuries. When offenders had SMI, conflict was less likely to focus on family issues and more likely to focus on offenders' behaviors and to involve contextual characteristics related to mental illness. CONCLUSIONS: Efforts to prevent gun and other violence between non-intimate partner family members should target factors more strongly associated with violence than SMI (e.g. history of domestic violence, substance abuse). Intervening in family aggression by persons with SMI likely requires addressing unique circumstances these parties experience.

Perceived Isolation among Family Caregivers of People with Mental Illness.

Family members (who are overwhelmingly women) providing caregiving for individuals with mental illness (MI) are known to experience significant burden. Little research, however, has addressed how such burden can affect caregivers' personal time and perceived isolation. Using data from a survey of 1,505 family caregivers of adults with MI, authors examined the extent to which factors related to caregivers, care recipients, caregiving, and treatment are associated with caregivers' perceived isolation and the mediating role of caregivers' inadequate personal time. A series of multivariate logistic regression models and Sobel testing were performed. Half of caregivers perceived being isolated. Perceived isolation was positively associated with care recipients having a serious mental health problem, coresiding, effects of stigma, and caregivers having inadequate time for themselves. Perceived isolation was negatively associated with the ability to rely on others for help, caregivers being satisfied with the amount of community mental health services, and caregivers having received education on caregiving. Caregivers having inadequate time for themselves was most strongly related to perceived isolation. Female caregivers were more likely to experience isolation; however, this relationship was mediated through caregivers having less time for themselves than preferred. The article concludes with a discussion of the implications for social work practice.

Violence by Persons with Serious Mental Illness Toward Family Caregivers and Other Relatives: A Review.

ABSTRACT: Persons living with serious mental illness (SMI) are at a modestly increased risk of committing violence and are disproportionately likely to target family members when they do commit violence. In this article, we review available evidence regarding violence by persons with SMI toward family members, many of whom are caregivers. Evidence suggests that a sizable minority of family members with high levels of contact with persons with SMI have experienced violence, with most studies finding rates of past year victimization to be 20% or higher. Notable risk factors for family violence pertaining specifically to persons with SMI include substance use, nonadherence to medications and mental health treatment, history of violent behavior, and recent victimization. Notable risk factors pertaining specifically to the relationships between persons with SMI and family members include persons with SMI relying on family members for tangible and instrumental support, family members setting limits, and the presence of criticism, hostility, and verbal aggression. As described in qualitative studies, family members often perceive violence to be connected to psychiatric symptoms and inadequate treatment experiences. We argue that promising strategies for preventing violence by persons with SMI toward family members include (1) better engaging persons with SMI in treatment, through offering more recovery-oriented care, (2) strengthening support services for persons with SMI that could reduce reliance on family members, and (3) supporting the capabilities of family members to prevent and manage family conflict. The available interventions that may be effective in this context include McFarlane's Multifamily Group intervention and the Family-to-Family educational program.

Risk Factors for Criminal Recidivism Among Persons With Serious Psychiatric Diagnoses: Disentangling What Matters for Whom.

Reducing criminal legal system involvement requires an understanding of the factors that promote repeat offending (i. e., recidivism), and the dissemination of relevant interventions to those most likely to benefit. A growing body of research has established common recidivism risk factors for persons with serious psychiatric disorder diagnoses. However, research to date has not examined the degree to which these risks apply to those with serious psychiatric disorders with and without co-occurring substance use disorders. To clarify what risk and need factors are greatest and for whom, this cross-sectional study drew from an original dataset containing data on 14 social and economic, psychological, and criminal risk areas for a cohort of people on probation (n = 4,809). Linear regression models indicated that, compared to those without a serious psychiatric disorder, people on probation with a serious psychiatric disorder are at greater risk in a minority of areas and those areas are mostly social and economic in nature. Meanwhile, those withco-occurring disorders are at relatively high risk across almost all areas. The results from this study suggest that justice involved persons with serious psychiatric disorders will benefit from interventions that increase social support and economic well-being and that interventions that broadly reduce risk among people with co-occurring serious psychiatric and substance use disorders will likely yield meaningful reductions in system involvement. Ultimately, understanding and intervening upon risk for recidivism among persons with serious psychiatric disorders requires differentiating between those with and without co-occurring substance use disorders.

Persons with serious mental illness help relatives: rates and correlates of assistance.

Background: Scant research has focused on assistance provided by persons with serious mental illness (SMI) to relatives.Aims: The objectives of the present study are to (1) describe and compare rates of assistance provided by persons with SMI to relatives and vice versa and (2) examine the extent to which factors are associated with assistance provided by persons with SMI.Methods: A cross-sectional survey design was employed. In 2014 and 2015, 573 adults with a relative with SMI completed an online survey. Multivariate logistic regression was computed.Results: Although persons with SMI were more likely to receive than provide assistance, 61% and 37% of persons with SMI provided relatives with assistance with activities of daily living (ADL) and financial assistance, respectively. Relationship type, co-residence and frequency of in-person contact were associated with providing assistance with ADL and financial assistance. Disability status and regular alcohol use were associated with assistance with ADL. Income was related to financial assistance.Conclusions: It is critical that researchers and practitioners acknowledge the help persons with SMI provide to relatives. Implications for research and practice are addressed.

Victimization and Perpetration of Violence Involving Persons With Mood and Other Psychiatric Disorders and Their Relatives.

OBJECTIVE: This study aimed to examine the rate at which persons with psychiatric disorders were victims of violence by reference relatives and the extent to which victimization and perpetration co-occurred in this population. METHODS: A total of 523 adults with a psychiatric disorder completed an online survey. Chi-square and Fisher's exact tests were computed. RESULTS: Since first diagnosis, 25% and 26% of respondents reported having been a victim of violence by reference relatives and having committed violence toward reference relatives, respectively. Thirteen percent of respondents reported having been a victim of violence by reference relatives, and 12% reported having committed violence toward reference relatives in the past 6 months. Victimization and perpetration often co-occurred. CONCLUSIONS: The risk of victimization and perpetration of family violence among persons with psychiatric disorders should be acknowledged. Assessing for risk of perpetrating family violence and intervening in such cases should entail assessing for and/or addressing victimization, and vice versa.

Safety Fears Held by Caregivers about Relatives with Psychiatric Disorders.

In this period of post-deinstitutionalization, much of the care for people with severe psychiatric disorders (PD) is provided by their families. A primary stressor for caregivers is fears regarding their own safety and that of others, which has been virtually unexplored. To fill this gap, factors in three domains were assessed: (1) relatives with PD, (2) family caregivers, and (3) interactions with each other. This investigation was a secondary analysis of data obtained from a national survey of caregivers of adults with mental illness conducted by the National Alliance for Caregiving. A subsample of 1,505 was used in the present study. Fear of harm was positively associated with the following factors: relatives with PD-serious mental health problem, alcohol and substance abuse, receipt of crisis mental health treatment, history of arrest; interaction-greater difficulty getting relative to take medications as prescribed; and fear that relative would be hurt by others or die by suicide. Social workers need to be cognizant of risk of potential violence against caregivers and ensure the safety of these family members, even if they may not be their primary clients. The article includes recommendations for family inclusion in the treatment of people with PD.

Characteristics associated with family money management for persons with psychiatric disorders.

BACKGROUND: Persons with psychiatric disorders (PD) commonly have their money officially or unofficially managed by others, with money managers most commonly being family members. AIMS: (i) Identify characteristics of persons with PD, adult family members, and interactions with each other significantly associated with family money management (FMM). (ii) Identify significant differences in aforementioned characteristics between official versus unofficial FMM. METHODS: Five hundred and seventy-three adults residing in USA with an adult relative with PD completed a survey. RESULTS: Among persons with PD, FMM was positively associated with lower income, diagnosis of schizophrenia/schizoaffective or bipolar disorder, psychiatric hospitalization, and arrest history. FMM was negatively associated with family members having a mental health diagnosis. FMM was positively associated with interaction characteristics of co-residence, financial assistance, caregiving, and use of limit-setting practices. Compared to official FMM, when unofficial FMM was present, persons with PD were less likely to have been psychiatrically hospitalized or to have regularly attended mental health treatment. When unofficial FMM was present, adult family members were less likely to be a parent of the person with PD. CONCLUSIONS: Practitioners should assess the level of burden experienced by family money managers and assess and address with family money managers the use of limit-setting practices.

Caregiving for Relatives with Psychiatric Disorders vs. Co-Occurring Psychiatric and Substance Use Disorders.

Despite the high comorbidity of psychiatric and substance use disorders, extremely little research has examined the experience of caregiving for relatives with co-occurring psychiatric and substance use disorders (COD). The primary objective of the present article is to identify characteristics pertaining to care recipients, family caregivers, and the experience of providing caregiving associated with care recipients having COD vs. only having psychiatric disorders (PD). A U.S. community recruited sample of 1394 family caregivers of persons with COD or PD was employed. Chi-square and Mann-Whitney-Wilcoxon tests were conducted. Compared to caregivers of persons with only PD, caregivers of persons with COD provided slightly less caregiving but experienced significantly greater negative effects from providing care. Caregivers of persons with COD were also more likely to fear care recipients would engage in multiple problematic behaviors. Most significant differences found in providing care to recipients with COD vs. only PD persisted when examining care recipients with severe psychiatric disorders or more moderate psychiatric disorders. Additional findings and treatment implications are described.

Elder Mistreatment Perpetrators with Substance Abuse and/or Mental Health Conditions: Results from the National Elder Mistreatment Study.

A large portion of persons who commit elder mistreatment have long been known to have indicators of substance abuse and/or mental health conditions (SAMHC). However, few studies have specifically examined elder mistreatment by persons with SAMHC, preventing the development of specialized intervention strategies. Using results from the National Elder Mistreatment Study, the current article examines victim, perpetrator, and interaction characteristics between cases of emotional and physical elder mistreatment in which the perpetrator is reported to have vs. not have SAMHC. Chi square tests and Mann-Whitney-Wilcoxon non-parametric tests were performed. 210 perpetrators of emotional elder mistreatment were reported to have SAMHC with 412 perpetrators of emotional mistreatment reported to not have SAMHC. 57 perpetrators of physical elder mistreatment were reported to have SAMHC with 38 perpetrators of physical mistreatment not having SAMHC. Emotional elder mistreatment committed by persons with SAMHC was associated with the following characteristics: perpetrator-unemployment, history of involvement with police, and fewer friendships; victim-female gender, greater emotional problems, and greater occurrences of lifetime emotional mistreatment; interaction-co-residence, and reporting of mistreatment to authorities. Physical elder mistreatment committed by persons with SAMHC was associated with police involvement of the perpetrator and greater occurrences of lifetime physical mistreatment experienced by the victim. These findings indicate that victims of elder mistreatment by persons with SAMHC are in particular need of intervention services as they have greater histories of mistreatment and experience greater emotional problems. Implications for effectively intervening in cases of elder mistreatment by persons with SAMHC are discussed.

Rates of Victimization of Violence Committed by Relatives With Psychiatric Disorders.

Persons with psychiatric disorders are at an increased risk of committing violence, with approximately half of all violence being perpetrated against family members. However, family violence perpetrated by persons with psychiatric disorders is a highly under-researched area, so much so that it is impossible to even approximately estimate the extent of the problem. This article presents the results of a national online survey of 573 adults with an adult relative with psychiatric disorders. Nearly half (47%) of all respondents reported being the victim of violence committed by their relative with psychiatric disorders since the onset of their relative's illness, and 22% reported being the victim of such violence in the past 6 months. Being the victim of minor versus serious violence was examined. The results of this study, in combination with sparse research previously conducted, suggest that 20% to 35% of persons with high levels of contact with a relative with psychiatric disorders have been the victim of violence committed by their relative with psychiatric disorders in the past 6 to 12 months, and that at least 40% have been the victim of said violence since the onset of their relative's illness. In the present study, no statistically significant differences were detected in rates of victimization based on the relationship type of the respondent to their relative with psychiatric disorders. It is imperative that further research be conducted that may inform the development of policies and interventions aiming to prevent family violence perpetrated by persons with psychiatric disorders.

Factors related to abuse of older persons by relatives with psychiatric disorders.

INTRODUCTION: Across developed nations, elder abusers have been found to disproportionately have indicators of psychiatric disorders (PD); however, elder abuse by persons with PD has received almost no research attention. The present analysis examines the association of perpetrator, victim, and interaction factors with the occurrence of physical, financial, and psychological abuse of older persons, committed by relatives with PD. METHODS: Data are from a U.S. community recruited survey of 243 persons 55 years of age and older who report having an adult relative with PD. Multivariate logistic regression was performed examining the association of proposed factors with the occurrence of physical, financial, and psychological abuse. RESULTS: In the past 6 months, 15%, 20%, and 42% of respondents reported experiencing physical, financial, and psychological abuse by relatives with PD, respectively. All forms of abuse co-occur at statistically significant levels. There is variation among factors associated with physical, financial, and psychological abuse; however, all types are associated with greater use of limit-setting practices and either regular attendance of mental health treatment or use of medications. CONCLUSIONS: Efforts to prevent abuse of older persons may benefit from linking suspected/substantiated elder abusers with PD to mental health treatment. Older persons engaging in high levels of limit-setting practices towards relatives with PD may benefit from being offered support and guidance regarding how to set limits in ways less likely to escalate conflict.

Factors associated with family violence by persons with psychiatric disorders.

Family violence by persons with psychiatric disorders (PD) is a highly under-researched area. The primary objective of the present analysis was to identify perpetrator, victim, and interaction/relationship factors associated with this phenomenon. The secondary objective was to examine the extent to which the relationship between caregiving and family violence was mediated by limit-setting practices used towards relatives with PD. 573 adults across the U.S. with an adult relative with PD completed an online survey. Multivariate logistic regression was performed examining the association of factors with the occurrence of family violence. Mediation was assessed with Sobel testing. Family violence was significantly associated with the following factors: perpetrator-income, illegal drug use, psychiatric hospitalization, treatment attendance, and use of medications; victim-age, employment status, income, and mental health status; interaction/relationship-parental relationship, co-residence, use of limit-setting practices, representative payeeship, and unofficial money management. Mediation was statistically significant. Increasing access to mental health and/or substance abuse treatment may decrease the risk of family violence. Interventions may benefit from attempting to decrease/modify the use of limit-setting practices. Where family representative payeeship or unofficial money management exists, it is advisable for practitioners to assess and address financial coercion and promote greater collaboration in financial decision-making.