Research That Matters (January 17 - 20, 2008)

Purpose: Long-term co-residence may take a severe toll on both the adult with serious mental illness and the caregiving parent. Co-residence often increases the parent's caregiving burdens. The death of the parent may result in severe and long-term grief of the mentally ill adult. Early and gradual preparation for this inevitable change of life is thus crucial. While research has explored the end of the co-residence, investigation on how mental health services may facilitate the transition out of co-residence has significance on enhancing both the parent's and the adult's well-being. However, practices of assisting in this transition have not yet been researched. This study examined how case managers in Assertive Community Treatment (ACT) programs assisted adult mentally ill clients and their parents in transitioning from the parents' house to independent living, with foci on case managers' conceptualizations of client independence, related assessments, and work strategies.

Methods: Grounded theory methodology was applied to conceptualize ACT case managers' practices on client independent living. Twenty-four case managers participated in the study, representing 10 programs over 7 counties in southern Wisconsin. The participants were predominantly white, yet varied in age (26 – 57 years) and time in the current position (8 – 240 months). The process of grounded theory studies resembles a helix where data collection, dimensional analysis, and theoretical sampling are intertwined. Data were collected through one-on-one, in-depth interviews. An interview was verbatim transcribed and then analyzed before proceeding with another interview. Interview questions thus evolved on the basis of ongoing analysis. Data were analyzed in an interdisciplinary research group by following a line-by-line coding procedure to identify and dimensionalize conceptual categories in the text (Schatzman, 1991). Theoretical sampling, a purposive sampling strategy, guided the collection of data specifically related to key conceptual categories.

Results: Concerning both independence as a social norm and the long-term client well-being, these ACT case managers conceptualized promoting client independence as a primary goal and independent living as an important task to accomplish. To achieve client independent living, case managers assessed: (1) client conditions, including client awareness of mental illness, stability of psychotic symptoms, independent living skills, and concerns of substance abuse and (2) the client-parent relationships, including healthy, enmeshed, indifferent, and conflicting relationships. Not only did these two domains interact, but the client-parent relationships also influenced the parent's agreement with, and the client's wish for, independent living. Case managers explicitly employed different work strategies depending on the presence or absence of the mutual agreement between the client and the parent with the goal, while working toward attaining client independent living.

Conclusions and Implications: This study delineates a form of intervention that ACT case managers used to achieve client independent living and to eventually relieve parent caregiving burdens. This requires case managers to work with not only the clients but also family dynamics in community settings. Findings highlight the importance of professional training on the complex assessments and on the skills to navigate through the transition. Critiques on the notion of independence suggest future research from different cultural perspectives.