The implementation of family-focused practice in adult mental health services: A systematic review exploring the inﬂuence of practitioner and workplace factors

: There is increased recognition of the need for greater and more appropriate support to be offered to families in which a parent experiences mental illness and has dependent children. One way of meeting this need is for adult mental health services to take a more family-focused approach. However, there are recognized difﬁculties in facilitating family-focused practice (FFP). The current review systematically synthesized quantitative and qualitative literature of practitioner perspectives and experiences of FFP in adult mental health settings to identify modiﬁable factors associated with its successful implementation. Five databases were searched systematically leading to the inclusion and quality assessment of 19 papers, ten of which were quantitative and nine qualitative. Analysis was guided by a narrative synthesis approach. Factors shown to inﬂuence FFP functioned at both practitioner and workplace levels and included personal attitudes, beliefs about job role, and perceptions of workplace support. Practitioners who felt that a family-focussed approach was inappropriate or detrimental to service users or outside of their remit as mental health professionals were less likely to adopt this approach. For those who saw the potential beneﬁts of FFP, lack of conﬁdence in their ability to deliver such an approach and lack of training can be barriers, as can lack of support and resources within services. This review highlights the need for actions to boost the awareness of adult mental health practitioners working with parents and to increase their conﬁdence. It also makes the case for broader organizational support if family-focussed practice is to be implemented successfully.


INTRODUCTION
Serious mental illness (SMI) in parents can have a significant impact on children, affecting their physical and mental health as well as their social and emotional well-being (Bee et al. 2014;Schrank et al. 2015). Conversely, family relationships, including those with dependent children, can have substantial impacts, both positive and negative, on individuals experiencing mental health difficulties (Barrowclough & Hooley 2003;Glynn et al. 2006;Lee et al. 2013;Waller et al. 2018). A substantial minority of psychiatric patients are parents, with studies revealing that up to 45% are parents to dependent children (Maybery & Reupert, 2018). Support is sometimes lacking for these families, and adult mental health services might have a role to play in improving outcomes for all family members (Bee et al. 2014;Reupert et al. 2015). A more 'family-focused' approach to mental health services has already been adopted, or is beginning to be, in several countries around the world, primarily in Australia, Finland, Norway, Canada and the Republic of Ireland (Mulligan et al. 2019;Reupert et al. 2015), reflecting increased recognition of the reciprocal effects of parent and child relationships and emerging evidence that such an approach is beneficial (e.g. Foster et al. 2012).
There is a 'lack of definitional clarity and theoretical integration ' (p. 131, Foster et al. 2016) about what exactly is meant by the term 'family-focused practice' (FFP), a practice which seeks to address the needs of the whole family, not just the parent with mental illness and as such typically involves increased collaboration between adult and child mental health services. Foster et al. (2016) conducted a systematic review of the concept and scope of FFP in adult, child, and youth mental health settings and identified six key interrelated components to existing FFP: (i) family care planninginvolving establishing goals and crisis plans; (ii) family and service liaison and advocacy; (iii) individual and family-focused support; (iv) individual and family-focused assessmentincluding identifying children and assessing parental competency, mental health impact and mental health literacy; (v) psychoeducation; and (vi) family-focused collaboration, which encompasses ensuring coordinated support from services to families. Foster et al. (2016) recommended four principles to be a starting point for FFP: the belief that 'consumers' families play a pivotal role in their recovery; that consumers and their families can be empowered to address and meet their needs; that it is possible to support consumers via their family; and that the relationships between clinician and consumer, clinician and family, and between consumer and family members, are key to enabling a "whole of family" approach ' (p. 151, Foster et al. 2016). Whilst these seem to be relatively straightforward principles in theory, in practice they can be difficult to operationalize and implement.
In a review of the barriers to working with families experiencing parental mental illness as perceived by adult mental health staff and the families accessing these services, Maybery and Reupert (2009) examined 28 papers and identified five themes that appeared to influence practitioners' family-focused approaches. These themes comprised of (i) policy and management, (ii) interagency collaboration, (iii) worker attitude, skill and knowledge, (iv) the client themselves, and (v) the client's family, including their children. The authors emphasized the need to prioritize organizational change in policy and management to successfully implement a family-focused approach within services. Maybery and Reupert's (2009) review was valuable in providing an overview of factors affecting practitioners' family-focused approaches within adult mental health settings. Particular strengths lay in the authors' efforts to capture all relevant studies and include clients' and family members' perspectives but as family-focused practice has increased, more research has been conducted and an updated review is needed. A more recent review by Shah-Anwar et al. (2019) synthesized practitioner experiences of FFP in both child and adult settings but focused solely on qualitative reports (nine in total). Conclusions were similar to those of Maybery and Reupert (2009) and highlighted the importance of the organizational context and policies supportive of FFP (theme 1) and clinicians' attitudes, knowledge and practice (theme 2). This review is an important addition to the literature but quantitative studies exploring implementation of FFP were excluded, including a large number conducted since the Maybery and Reupert (2009) review; therefore, a more comprehensive and up-to-date review is timely.

Aims
The current review sought to synthesize both the quantitative and qualitative literature examining practitioner experiences of the implementation of family-focused practice in adult mental health services systematically with the aim of providing an account of factors that should be addressed if FFP is to be implemented elsewhere, for example in the United Kingdom. It also aimed to identify the key factors that have been reported to have influenced practitioners' implementation of FFP in adult mental health settings in order to make evidence-based recommendations about how FFP should be implemented in adult mental health services attempting to adopt FFP for the first time. In doing so, this review may inform policy development and service delivery concerning the ways adult mental health services might incorporate family-focused approaches, with the longer term aim of helping families affected by parental mental illness overcome the challenges they face.

Search strategy and review scope
The search strategy was conducted in line with PRISMA guidance (Moher et al. 2009), and a protocol was submitted and registered on the PROSPERO database (CRD42019120756). Search terms were identified from the titles and abstracts of a selection of key papers, using Foster et al.'s (2016) review to encompass all FFP-related search terms. An initial pilot search was then undertaken using 'family-focused practice', 'adult mental health practitioner' and 'influential factor' related search terms (see Table 1 for a full list of search terms). An 'influential factor' was defined as any variable that had been examined in relation to its possible impact on the FFP of adult mental health practitioners. The pilot search indicated that influential factors would be better identified through hand-searching as part of the screening process to avoid imposing restrictions and bias by pre-defining search terms. Consequently, five electronic databases (PsycINFO, CINAHL plus, ASSIA, BNI, and Web of Science) were searched using 'family-focused practice' and 'adult mental health practitioner' related search terms only. Both quantitative and qualitative studies published in the English language from database inception until 3 November 2018 were included in order to ascertain a deeper understanding of the influence of factors on FFP whilst synthesizing their quantifiable impact.
It was beyond the scope of this review to incorporate client perspectives or wider organizational issues, as examined by Maybery and Reupert (2009). To better facilitate more targeted recommendations, the current review sought to identify which modifiable practitioner and workplace factors influenced the FFP of practitioners working in adult mental health services, and determine where this impact was seen. Therefore, the decision was also made to exclude some potentially influential demographic factors (such as age and gender of practitioners; their parental and marital status and geographical location) due to the difficulty of implementing such findings for services.

Inclusion and exclusion criteria
Inclusion criteria for studies reporting on factors influencing FFP were as follows: (i) participants were adult mental healthcare practitioners who worked in adult mental health services, (ii) studies included data on factors that influenced FFP at a practitioner and/or workplace level, and (iii) papers were available in English in peer-reviewed journals.
Exclusion criteria were (i) participants were mental healthcare practitioners working in child, substance use or physical healthcare roles, or occupying a solely managerial, non-clinical position, (ii) studies that described data relating to factors affecting the implementation of a specific short-term intervention or clinical trial relating to family-focused work, (iii) research reporting on specific types of therapy involving families (such as Family Therapy or Family Intervention), and (iv) reviews and/or studies not presenting empirical data, such as opinion pieces and audits.
Studies that included data from a mixed sample (e.g. clients and practitioners) were included if the practitioners' data were presented separately but excluded if they were combined. Whilst papers were included if they explored the impact of factors on FFP following national family-focused policy implementation, studies were excluded if they only examined factors affecting the implementation of specific family-focused interventions or clinical trials (i.e. specific time-limited interventions that did not constitute attempts to adopt FFP more widely). This distinction was made because the focus of the review was on synthesizing evidence on modifiable factors influencing the implementation of FFP within adult mental health services only.
A rater not linked to the study (RF) independently screened the titles and abstracts of 10% of the papers (n = 1427). When there was disagreement, this was discussed with the wider team and consensus reached. An interrater reliability score of j = 0.77 was attained, indicating substantial agreement and reasonable reliability. See Table 2 for the full inclusion and exclusion criteria, and Figure 1 for the flow diagram of the search strategy.

Data extraction and synthesis
The second author (HA) led on assessing eligibility, extracting the data and quality appraising the included articles, consulting with the research team throughout this process. Two published reviews (Foster et al. 2016;Maybery & Reupert 2009) were used to guide data synthesis, but it was agreed to diverge from the structures proposed in those papers should the current data extraction and analysis process reveal a different picture.
Data analysis from quantitative and qualitative studies was guided by a narrative synthesis approach (Popay et al. 2006) to review and synthesize primarily textual data of multiple studies in order to assimilate findings. Quantitative and qualitative data were initially analysed separately and then combined in the synthesis process to present a collective narrative of influential factors. Relevant questionnaire data were extracted from the quantitative studies first, and verbatim quotes were then extracted from the qualitative papers. Extracted data were tabulated according to: (i) the factors appearing to influence FFP, drawing on Maybery and Reupert's (2009) review to broadly distinguish between practitioner and workplace factors and (ii) the FFP component the factors seemed to influence, using the categorization proposed by Foster et al. (2016) as an initial framework to classify the component of FFP reported being impacted.

Methodological quality assessment of the included studies
The quality of studies was appraised using reputable appraisal tools that were appropriate for the methodology of each included study. A 10-item checklist from the Critical Appraisal Skills Programme (CASP 2018) was used to assess the qualitative papers. No appropriate CASP tool existed for the quantitative studies (all utilizing cross-sectional survey designs), and the 21-item Critical Appraisal Checklist for the Appraisal of Surveys tool (Crombie, 2002) was used to appraise these. The quality appraisal rating key proposed by Boland et al. (2014) was used. Studies were rated 'high' quality when most of the criteria were met or the paper showed notable methodological strengths, 'adequate' when most of the criteria were met, and 'low' when the study only partially met appraisal criteria. After another external rater (JB) independently appraised over 25% of the included papers, the interrater reliability score of j = 0.72 indicated substantial agreement.

Characteristics of included studies
A description of all 19 included studies is provided in Table 3. Most studies were conducted in Australia (n = 8) and Finland (n = 3). Remaining countries included Norway (n = 2), Ireland (n = 2), the UK (n = 2), Thailand (n = 1), and Sweden (n = 1). Most countries had introduced national FFP policies except for Thailand, Sweden, and the UK.
Ten studies were quantitative and nine were qualitative, and sample sizes ranged from 6 to 349 participants with a combined sample of 1493. Of the quantitative papers, three reported data from the same Australian sample (Goodyear et al. 2017;Maybery et al. 2014Maybery et al. , 2016, and three papers reported data from the same Finnish sample (Korhonen et al. 2010a;Korhonen et al. 2008Korhonen et al. , 2010a. Two qualitative papers published data from the same sample (Tchernegovski et al. 2018a(Tchernegovski et al. , 2018b, hence the 19 studies were drawn from 14 datasets. The 10 quantitative studies were cross-sectional studies providing self-report survey data. Four (Goodyear et al. 2017;Maybery et al. 2014Maybery et al. , 2016Tungpunkom et al. 2017) used adapted versions of the 'family-focused mental health practice questionnaire' (FFMHPQ) (Maybery et al. 2012). Three studies by Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b) used a 135-itemquestionnaire, which was subsequently published as the 'preventive child-focused family work' (PCF-FW) questionnaire (Korhonen et al. 2009). The remaining three studies (Houlihan et al. 2013;Lauritzen et al. 2015;Slack & Webber 2008) used questionnaires developed for their specific research purposes; the latter two of which included open-ended textual responses which were analysed qualitatively.
Eight of the nine qualitative studies used interviews as data collection methods including one focus group (Sj€ oblom et al. 2005), whereas one study (Lauritzen & Reedtz 2013) presented only the qualitative data from a questionnaire, having published the quantitative data in a separate paper (Lauritzen et al. 2015).

Methodological appraisal
Quality appraisal revealed three quantitative studies to be 'high quality' (Houlihan et al. 2013;Slack & Webber 2008;Tungpunkom et al. 2017) and seven 'adequate quality. Collectively, study strengths lay in the frequent reporting of response rates (n = 7), statistical analysis methods (n = 9), and in discussions of possible selection bias (n = 6). The quality of studies was hampered by null findings either being partially reported (n = 5) or omitted entirely (n = 4). Inconsistent or inaccurate data reporting was evident, such as variations in the reported sample sizes, mathematical errors in the reported response rates, and data differences between that reported in the text and tables (n = 7). Furthermore, as all the quantitative studies were cross-sectional surveys administered to staff to complete, the limitations of selfreport questionnaire data were applicable throughout.
Four of the nine qualitative studies were rated 'high quality' Maddocks et al. 2010;Tchernegovski et al. 2017Tchernegovski et al. , 2018b and three 'adequate quality' (Sj€ oblom et al. 2005;Tchernegovski et al. 2018a;Ward et al. 2017). Two studies only partially met appraisal criteria quality standards (Lauritzen & Reedtz 2013;O'Brien et al. 2011). The qualitative studies tended to report reasonably rigorous analysis, with two scoring highly in relation to in-depth description of the analytical process Maddocks et al. 2010). However, six of the nine studies did not critically consider researcher influence Lauritzen & Reedtz 2013;O'Brien et al. 2011;Sj€ oblom et al. 2005;Tchernegovski et al. 2017;Ward et al. 2017) and possible resulting bias is therefore a significant limitation. Detailed quality appraisal ratings are shown in Appendix S1.

Data synthesis
This review set out to identify which practitioner and workplace factors influenced the FFP of adult mental health practitioners and describe which practices they influenced. Practitioner factors included personal attitudes and professional subfactors, whilst workplace factors included service-related and support-related subfactors. The thematic structure of results is illustrated in the following diagram ( Figure 2).
The included papers reported data on the influence of factors on family-focused assessment and support practices almost exclusively. Some limited data on family-focused collaboration practices between adult mental health services and other organizations were presented. By definition, however, collaborative practices cannot be wholly influenced by adult mental health services because they are inherently reliant on relationships with other organizationsorganizations which may adopt alternative stances. Hence, we omitted these data from the review in order to present more targeted, workable recommendations. For a full and detailed overview of results, see Appendix S2 showing factors reported to influence FFP.

Practitioner factors
Personal attitudes Personal beliefs about FFP. Nine papers reported on the influence of practitioner attitudes and beliefs on FFP Lauritzen et al. 2015;Maddocks et al. 2010;O'Brien et al. 2011;Sj€ oblom et al. 2005;Slack & Webber 2008;Tchernegovski et al. 2018aTchernegovski et al. , 2018bWard et al. 2017); eight of which presented qualitative data of broadly good quality. In the only quantitative study (Lauritzen et al. 2015), no significant differences were seen between practitioners who did assess whether clients had children and those that did not in terms of their attitudes and beliefs about FFP. However, the eight studies presenting qualitative data offered a different picture in which attitudes and beliefs were reported to have a considerable influence on FPP. Five studies described substantial reservations about taking a family approach, in which practitioners reported that involving children in patient care was inappropriate or detrimental to clients (Maddocks et al. 2010;O'Brien et al. 2011;Sj€ oblom et al. 2005;Slack & Webber 2008), or that the value of a family-focused approach was overstated (Maddocks et al. 2010;Sj€ oblom et al. 2005). Family approaches were also described as being outside the remit of adult mental health work Maddocks et al. 2010 Nevertheless, across these ten studies practitioners also expressed positive attitudes about the benefits of incorporating family approaches. Participants reported that involving children and families increased the likelihood of parents' mental health improving and parents staying well (Maddocks et al. 2010 Personal attitudes about ability to practice FFP. With regard to practitioners' beliefs about their abilities to take on family-focused approaches, some reported feeling best placed to identify and manage parenting concerns with clients accessing their service Maddocks et al. 2010;Tchernegovski et al. 2018aTchernegovski et al. , 2018b).
There's a whole cycle that goes into what we do with families, that gives us a different relationship with people and allows us to make interventions in a different way than the various other professionals that are coming in.
(p. 210;  Indeed, negative beliefs about involvement from external services incentivized some practitioners to take a family approach in their work (Lauritzen & Reedtz 2013;Maddocks et al. 2010;Tchernegovski et al. 2018aTchernegovski et al. , 2018b. The likelihood that involving clinicians from other services (such as children's services) would be perceived badly by parents was highlighted by a practitioner, who consequently reported experiencing a 'really strong motivator for me to raise [the issue], even when it's uncomfortable' (p.384; Tchernegovski et al. 2018b).
Nevertheless, even practitioners who reported positive attitudes towards FFP expressed concurrent beliefs about it being difficult. In four studies, practitioners described the risk of FFP adversely impacting their relationship with clients and any developing trust (Lauritzen & Reedtz, 2013;Maddocks et al. 2010;Slack & Webber 2008;Tchernegovski et al. 2018a).
If they feel that we are involved with the children and that we are part of that decision-making process it can ruin the relationship, and we are trying to build up a good therapeutic relationship to help them move on.
(p. 678; Maddocks et al. 2010) [You] take on an authoritarian role instead of a clinician role. . . you've moved across the line from someone who's trying to help them to someone who's against their will.
(p. 5, Tchernegovski et al. 2018a) The tension between being family-focused and person-centred was highlighted in several studies (Maddocks et al. 2010;O'Brien et al. 2011;Tchernegovski et al. 2018aTchernegovski et al. , 2018bWard et al. 2017). This meant some practitioners considered parenting issues only when raised by the client themselves ('we leave it up to the family to ask about children visiting 'p. 360;O'Brien et al. 2011) and could result in FFP being limited to practitioners simply providing a space for their client to 'let off steam' (p. 5; Tchernegovski et al. 2018a).
Others highlighted the difficulties of collaborating with families and indirectly assessing family functioning via parents' accounts (Lauritzen & Reedtz 2013;Sj€ oblom et al. 2005;Tchernegovski et al. 2018aTchernegovski et al. , 2018bWard et al. 2017). Tchernegovski et al. (2018b) reported this was particularly pertinent around risk mattersit could be 'very difficult to be clear about predicting issues of safety' when 'you've got to rely on what [the parent is] saying' (p. 385).
Practitioners also spoke about an emotional cost of family-focused work, particularly in terms of the empathic response often invoked when working with parents and children, and felt this could be overlooked Maddocks et al. 2010;O'Brien et al. 2011;Tchernegovski et al. 2017Tchernegovski et al. , 2018aTchernegovski et al. , 2018b Overall, evidence suggested that practitioners' personal attitudes towards FFP and their ability to use it impacted upon the family-focused approaches they adopted in two main ways. Firstly, the likelihood of practitioners engaging in FFP was closely linked to their beliefs about the benefits of work to their clients and families. Secondly, the extent to which practitioners engaged in FFP was influenced by beliefs about their ability to do such work, but also their beliefs about ways to overcome the inherent, inevitable challenges.
Professional subfactors Family-focused training and education. Five quantitative studies examined the influence of familyfocused training and education on practitioners' FFP (Goodyear et al. 2017;Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bTungpunkom et al. 2017), and all five reported some evidence that training positively impacted upon FFP. However, the picture is complicated by two of these studies differentiating between 'family training' and 'child training' but not describing how training differed (Goodyear et al. 2017;Tungpunkom et al. 2017), and by reporting that 'family training' or 'child training' only influenced certain aspects of familyfocused assessment and/or support. The three remaining studies are a series of linked papers reporting data from a single sample (Korhonen et al. 2008(Korhonen et al. , 2010a(Korhonen et al. , 2010b and only report on 'further family education' without providing a description of what this entailed. Goodyear et al. (2017) and Tungpunkom et al. (2017) found that practitioners who had undertaken either family training or child training were significantly more likely to assess the impact of parental mental illness on children than practitioners who had not received this training. This result was supported by Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b, who reported that participants who had undertaken further family education were more likely to gather information about clients' children and assess family well-being and support networks. Similarly, Goodyear et al. (2017) reported that practitioners who had received family training were more likely to assess parents' awareness of their children's well-being as well as offer parenting support, support carers and children, and make referrals for family members. Tungpunkom et al. (2017) also found that family-trained practitioners were more likely to support carers and children, but family training was not shown to influence the likelihood of them offering parenting support or making referrals. Child training did not influence the likelihood of practitioners providing parenting support (Goodyear et al. 2017;Tungpunkom et al. 2017), and Goodyear et al. (2017) also found no evidence that it influenced making referrals, offering family support, or assessing parents' awareness of their children's well-being.
The importance of feeling adequately trained in family-focused practice was highlighted in six studies reporting qualitative data ( Equally, family-focused training was seen to help practitioners feel more able to engage in FFP Houlihan et al. 2013;Tchernegovski et al. 2018b), as highlighted by one practitioner who explicitly stated 'I would like further education in how to deal with questions asked by children ' (p. 292;Houlihan et al. 2013) and another who felt training made them better able to assist families who were 'stuck in crisis ' (p. 384;Tchernegovski et al. 2018b).
The evidence therefore suggests that undertaking family-focused training and education has a positive influence on family-focused practice. However, these conclusions are partly based on the findings reported in quantitative studies with adequate methodological quality (e.g. Goodyear et al. 2017;Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bTungpunkom et al. 2017) and five qualitative papers (four of which were rated high quality) asserting the benefits of training for FFP.
Job role. Ten studies examined how aspects of job role influenced family-focused practice Houlihan et al. 2013;Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bO'Brien et al. 2011;Slack & Webber 2008;Tchernegovski et al. 2018a;Tungpunkom et al. 2017;Ward et al. 2017). Five studies presenting qualitative data reported practitioners seeing FFP as the role of certain professions and not others Houlihan et al. 2013;O'Brien et al. 2011;Tchernegovski et al. 2018a;Ward et al. 2017), as highlighted by a psychologist: The social workers do a lot of the family work and the doctors might talk to the family for collateral history and things like discharge planning. I'm a bit more oneon-one therapy with the client themselves. (p. 5;Tchernegovski et al. 2018a) This perceived distinction between professions was supported by two high quality quantitative studies. Tungpunkom et al. (2017) found that social workers were significantly more likely than psychiatrists, psychologists, and nurses to offer support to family members, whilst psychiatrists were more likely to assess the impact of parental mental illness on clients' children. Similarly, Slack and Webber (2008) reported that social workers were significantly less likely than all other mental health practitioners to report that supporting the children of parents with mental health difficulties was beyond their role remit, and care coordinators were significantly more likely to support clients' children and assess the need for multi-agency involvement. 1 Intriguingly, this same study found that nurses were significantly more likely than social workers to state that these children should 'always' be offered support.
Across their series of linked papers, Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b reported that factors which had a statistically significant impact on FFP (such as training, length of service, available resources, and workplace support) were seen in registered nurses but not practical mental health nurses (equivalent to healthcare assistants in the UK). This raises the question whether professional seniority may also have an influence on FFP, although Houlihan et al. (2013) found no evidence that seniority influenced the way in which mental health nurses assessed family setup or functioning, offered support, or worked collaboratively with other services.
The results indicating that job type influences FFP were not consistently upheld across studies; for example, Maybery et al. (2014) reported mixed results regarding the impact of job role upon aspects of family-focused assessment and support practices. Compared to psychiatric nurses and psychologists, social workers were significantly more likely to offer support to carers and children as well as assess the impact of parental mental illness on clients' children. However, there was no evidence of a significant difference between professions in terms of practitioners offering parenting support or assessing the parent's awareness of their child's well-being.
Since all studies except one were rated at least adequate quality, we concluded that some professions may be more likely to take a family-focused approach and/ or incorporate certain aspects of FFP into their work. Results suggested that social workers may be more likely than nurses, psychologists and psychiatrists to use a family-focused approach in their work, particularly in terms of offering support. There is also some evidence to suggest that psychiatrists may incorporate more family-focused assessment practices into their work than other professions.
Length of service in mental health work. Six quantitative studies examined the impact of practitioners' length of service in mental health work on FFP (Goodyear et al. 2017;Houlihan et al. 2013;Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bSlack & Webber 2008). Overall, results were mixed. According to Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b, practitioners who had 20 or more years' professional experience demonstrated the highest level of family-focused assessment and support practices. In contrast, Houlihan et al. (2013) found that practitioners who had been qualified for 10 years or less were more likely to engage in FFP. However, Slack and Webber (2008) reported that length of professional experience was not associated with practitioners' FFP. Similarly, Goodyear et al. (2017) noted that experience was not a significant predictor of family-focused assessment, and servicelength only explained 1.4% of the variance in a regression model predicting practitioners' provision of family and parenting support. Therefore, the evidence suggests that professional mental health experience might have some impact on family-focused practice, but it is not conclusive at this stage.
Skill and knowledge. Two additional quantitative papers of adequate quality investigated the influence of self-reported skill and knowledge around parental mental illness (Lauritzen et al. 2015;Maybery et al. 2016). Maybery et al. (2016) found that self-reported knowledge of the impact of parental mental illness on children was associated with family-focused assessment and support practices. They also determined that confidence in family-focused skills and knowledge was associated with assessment practices. Lauritzen et al. (2015) reported a statistically significant difference in favour of participants who did assess whether clients had children (compared to those practitioners who did not) and their knowledge of the impact of parental mental illness on children and FFP-related legislation.
These findings were supported in two qualitative papers (Maddocks et al. 2010;O'Brien et al. 2011) in which participants reported moments when they considered taking a family-focused approach but held back because they did not think they had adequate knowledge.
I often wonder if it would be appropriate for me to see what she was like with the child. . . but I wouldn't know what to look for.
(p. 679; Maddocks et al. 2010) Overall, the evidence suggests that practitioners' perception of their skill and knowledge around parental mental illness influences their FFP, but to date too few studies exist to confirm this.

Workplace factors
Service-related subfactors Available resources. Nine papers reported data on how having family-focused resources available impacts upon FFP Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bLauritzen et al. 2015;Maddocks et al. 2010;Maybery et al. 2016;O'Brien et al. 2011;Tchernegovski et al. 2017). Resources included workforce availability, physical space for family work, family-focused group programmes, and specialist tools. Studies broadly described how accessible resources helped practitioners shift from being family-minded to enacting FFP, as is illustrated in following quote from a qualitative study rated to be of high quality: There is impetus to change, but structures to allow this are not in place in services in terms of culture or concrete resources. Indeed, adequate quality quantitative evidence from Lauritzen et al. (2015) showed a statistically significant increase in practitioners identifying clients' children after a Family Assessment Form was introduced as part of a national family-focused policy implementation in Norway. However, the introduction of this form did not impact on practitioners' FFP beyond identifying whether clients had children. Similarly, Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b reported mixed results regarding any positive impact of family-focused group programmes and resources upon practitioners' FFP. Further adequate quality data from Maybery et al. (2016) showed that having clear family-focused policy and procedures in place did not predict participants' assessment or support practices.
Overall, there is reasonable agreement that practitioners identifying whether their clients have children would be enhanced by services implementing tools such as family-focused assessment forms. However, the evidence also indicates that whilst available resources may influence FFP, resources are not enough 'in and of themselves' to ensure a family-focused approach is adopted within services.
Work setting. Six papers reported on the influence of work setting (i.e. hospital versus community settings) on FFP Houlihan et al. 2013;Korhonen et al. 2008Korhonen et al. , 2010aKorhonen et al. , 2010bWard et al. 2017). Three of the four quantitative papers came from Korhonen et al. (2008Korhonen et al. ( , 2010aKorhonen et al. ( , 2010b who found some support for the influence of community settings influencing aspects of FFP but reported mixed findings overall. Houlihan et al. (2013) also found no evidence of workplace setting influencing practitioners' tendencies to assess family setup, family functioning, and support options.
The two qualitative papers reporting data on work setting presented a slightly different picture Ward et al. 2017). Both described community practitioners anticipating family involvement (when 'families wander into the room together anyway' p. 5; Ward et al. 2017) and being more likely to work collaboratively with colleagues from other professions. Being able to see family functioning in the home environment as part of community work was also reported to enhance practitioners' family-focused assessments.
Being able to go into the home is pivotal in being family-focusedyou're not only working with the service user, but you're also able to gauge the feelings and interpretations of the family members. (p. 209;  These findings suggest that work setting may have some influence on FFP, with community settings often adopting more of a family approach, especially in terms of assessment. However, this evidence is largely drawn from individual practitioners' reflections reported in one adequate and one high quality qualitative paper, limiting the extent to which results can be generalized. Location issues. Lauritzen and Reedtz (2013) reported one participant describing how working within remote rural locations was a barrier to collaborative practices with family members. This paper only partially met appraisal criteria, and this finding was not support by two adequate quality quantitative papers which found no significant difference between rural or urban locations and practitioners' assessment practices or support offered to family members (Goodyear et al. 2017;Maybery et al. 2016). Collectively, there was minimal evidence to suggest that location issues impacted on FFP.

SUPPORT-RELATED SUBFACTORS
Workplace support Tchernegovski et al. (2018a) reported that practitioners conceptualized 'workplace support' in relation to FFP as supervision, multi-disciplinary team discussions, informal and formal debrief sessions and specialist consultation meetings. Workplace support was explored in five qualitative studies and only one quantitative study, in which Maybery et al. (2016) found some evidence that co-worker support predicted clinicians offering support to parents and families, but not their assessment practices.
However, a richer picture was presented in the qualitative literature in which workplace support was seen to enhance FFP. Participants described how workplace support facilitated family-focused approaches by offering guidance about the direction of work and providing emotional support Lauritzen & Reedtz 2013;Tchernegovski et al. 2018aTchernegovski et al. , 2018b.
Equally, a lack of workplace support was also considered a barrier to FFP. Three high quality papers Slack & Webber 2008;Tchernegovski et al. 2017) and one lower quality paper (Lauritzen & Reedtz 2013) reported how lack of peer or managerial support obstructed FFP. Practitioners expressed how 'there needs to be a bigger approach to people as family units and all that that entails' (p. 211; Grant & Reupert 2016) but described how actions that concerned wider family functioning were often disregarded.
Sometimes it will be discussed in the team meeting and a conclusion drawn that. . . we don't have a suitable service for that child or family so it is taken no further. (p. 76;Slack & Webber 2008) Overall, workplace support had a positive influence on FFP, particularly when practitioners had support from their colleagues as well as management. At this stage, workplace support appeared to have more of an influence on the support that practitioners offered families than their assessment practices.

Time and workload
Time and workload issues were not investigated extensively throughout the literature. Only two qualitative papers reported participants' restricted time and heavy workload impacting their FFP because '[you] actually don't get a lot of time ' (p. 5;Ward et al. 2017) to 'do the extra work ' (p. 15;Lauritzen & Reedtz 2013). However, the relationships between time and workload issues and FFP were tested in a quantitative study  which showed no evidence that these issues affected either family-focused assessment or support practices.
Thus, time and workload issues did not influence the FFP of adult mental health practitioners; however, this has not been investigated extensively. It also is possible that time and workload barriers to FFP did not materialize due to wider sampling biases in which more family-minded practitioners took part in research into FFP.

DISCUSSION
This review sought to identify the key modifiable factors influential in the family-focused practice of adult mental health practitioners and highlight where these factors have their impact. Nineteen studies were included and analysed to determine which practitioner and workplace factors seemed to influence family-focused assessment and support practices. Although more work is clearly needed to firmly establish the links between practitioner and workplace factors and FFP, and to confirm which of these factors have the greatest impact on FFP, we were able to draw some tentative conclusions about the factors which might be most relevant to the adoption of FFP within adult mental health services.
The review found that personal attitudes, beliefs about job role, and perceptions of workplace support appeared to have a notable impact on practitioners' FFP. It is not surprising that the likelihood of practitioners engaging in FFP was closely linked to beliefs about the benefits of such work as well as beliefs about practitioners' ability to overcome the inherent challenges involved. This finding is supported by Foster et al.'s (2016) review in which the authors emphasized the dependence of FFP on 'clinician's willingness, capacity, and capability to see the relationship between the primary/referred person and their "key others" ' (p. 150; 2016). Similarly, some professions were more likely to take a family-focused approach and/or incorporate certain aspects of FFP into their work. Social workers were more likely than nurses, psychologists, and psychiatrists to use a family-focused approach in their work, particularly in terms of offering support, whilst psychiatrists incorporated comparatively more family-focused assessment practices into their work. Perceived workplace support from colleagues as well as management had a positive influence on FFP, particularly on support offered to families by clinicians.
Mixed results were noted regarding the influence of family-focused training and education, length of service in mental health work, self-reported skill and knowledge and available resources. As was emphasized in qualitative interviews, family-focused training and education positively impacted FFP. Similarly, practitioners' perceptions of themselves as skilled and knowledgeable about issues relating to parental mental illness seemed linked to the increased use of family-focused approaches. Evidence showed some impact of practitioners' length of service on FFP, but overall results were not consistent. It is possible that perceived skill and knowledge, effects of training, and length of service are interrelated and may act as confounding variables. Furthermore, the mixed results might also reflect the changing priorities within services in different countries, perhaps with newer staff being more likely to take FFP on board. Having available resources better facilitated FFP, albeit there was a recognition that such resources might not be sufficient in ensuring that family-focused approaches were adopted within services. Overall, the relatively few studies that contribute to the findings outlined here were of mixed quality, as is common in under-researched areas. Nevertheless, preliminary evidence suggests family-focused training, length of service, selfreported skill and knowledge and available resources are worthy of further investigation in order to determine their respective influence on FFP.
In contrast, there was minimal indication that practitioners' FFP was influenced by work setting (hospital versus community settings), location issues (rural vs urban locations) or time and workload issues. However, none of these factors have been investigated extensively. It is also possible that time and workload barriers to FFP are more subject to sampling biases than other factors, in which more family-minded practitioners tend to take part in research into FFP and are less likely to report time and workload issues as hindrances. Future research incorporating more diverse samples might tell a different story.
This review supports findings from Maybery and Reupert (2009) in that FFP is hindered by inadequate provision of resources, restrictive ideas about job role, negative beliefs about FFP and perceived lack of individual skill and knowledge of workplace support. However, findings from the current review offer a different perspective about possible solutions to that illustrated in Maybery and Reupert's hierarchy diagram (p. 789) which proposes that 'higher level activities [i.e. practitioner factors] will only be successful if they build on lower factors embedded in the organisation' (p. 788). The current review highlights that many of the factors influencing FFP were fundamentally about practitioners' perceptions, with personal attitudes, perceived workplace support, self-reported skill and knowledge all impacting FFP. There was some evidence that more service-based factors were insufficient 'in and of themselves' (e.g. available resources) or were not seen to have an influence on FFP (e.g. work setting and location issues), but there was insufficient data to draw a firm conclusion. More work in this area is required.
Focusing efforts on practitioner factors that work at the level of the individual may be pivotal in encouraging more family-focused approaches. Contrary to Maybery and Reupert's (2009) proposal, boosting FFP in adult mental health services might be better conceptualized as a reciprocal process between individual practitioner factors and wider workplace systems, rather than as a linear, hierarchical process.
In contrast to the six-component definition of FFP presented by Foster et al. (2016), the current review highlighted that research on the FFP of adult mental health practitioners had focused primarily on assessment and support practices, with some examination of collaborative working. The remaining three practices (i.e. psychoeducation, family planning and goal-setting, and family-service liaison) were either not investigated within the 19 papers identified or were referred to but were better subsumed under the overarching components of assessment and support. The fact that Foster et al. (2016) included papers recruiting from child as well as adult mental health settings might explain this discrepancy. Nevertheless, this finding is important because it indicates a clear two-stage process for practitioners aiming to incorporate more FFP into their work: to start implementing family approaches, practitioners firstly should assess whether the adults accessing their service are parents, and then secondly, they need to consider ways in which the wider family might be supported.
In terms of how best to focus efforts to encourage FFP within adult mental health services, the following targeted, evidence-based recommendations are proposed. To begin with, there needs to be an attitude shift on three levels: firstly, in terms of a formulationbased understanding of the reciprocal impact of parenting and mental health stressors; secondly, the resulting importance of taking a family approach in adult health work which includes consideration of any children; and thirdly, a reassertion of practitioners' capability not only to do this kind of work, but to offer unique skill and expertise from an adult mental health perspective. Such shifts in attitudes could be achieved by the inclusion of clear FFP targets within policy and associated training offered across the different professional backgrounds that typically comprise a multi-disciplinary team to emphasize that FFP is not just the remit of particular professions, as well as ensure that workplace support and responsibility around FFP is shared across the team. When personal attitudes, beliefs about job and perceptions of workplace support are more closely aligned with the principles of familyfocused approaches, the introduction of basic resources, such as family assessment forms, may help to boost practitioners' FFP. The current state of the literature on FFP indicates that these resources would need to prompt practitioners to identify whether their clients are parents of dependent children and remind them to enquire as to the type of support the parent might need, in addition to that of their family members. However, underpinning these shifts at the service and practitioner levels is the need for national policies to stipulate the inclusion of FFP which go beyond the recording of service users who are parents, for organizations to mandate and promote FFP, and to support their staff to achieve it. As Tchernegovski et al. (2017) report, the embedding of FFP practices is reliant on wider organizational factors such as reporting systems, meeting structures, and supervision. This review is limited by the fact that all included studies used questionnaires or interview methods, and as such are subject to the inherent bias of self-report data. By including only English language studies published in peer-reviewed journals, we also need to acknowledge possible language and publication biases. Nevertheless, a strength of this review lay in including both quantitative and qualitative studies which meant we were able to gather a deeper understanding of the All research study designs, that is both quantitative and qualitative Included papers must report on either quantitative or qualitative data which have been analysed by an established quantitative/qualitative methodology Opinion pieces; reviews; audits.

Dates
No dates specified Not applicable Language Articles written in English language Non-English language articles Peer reviewed Articles from peer-reviewed journals Articles from journals not peer reviewed research topic whilst synthesizing the extent of the influencing factors. As such, we have been able to present evidence-based recommendations drawn from new research which can be used to target efforts by focusing on identified factors known to influence implementation of family-focused approaches in adult mental health settings. This review highlights the need for further, high quality research, particularly in relation to what training in FFP would need to involve for it to be effective,    Community (4) Outpatient (1) Rehabilitation (1) Across units (3) Crisis (1) Intake (1) Geography: Regional (4) Rural (1) Suburban (6) Semi-structured interviews IPA High 4. Ward et al. (2017). Australia 'Family-focused practice within a recovery framework: practitioners' qualitative perspectives.' Aim: Explore practitioners' understandings of FFP within recovery framework  (4) Community (10) Semi-structured interviews Thematic analysis High (Continued) and how this could best impact practice. Researchers should focus on identifying the most effective way of using training to boost practitioners' skill and knowledge in order to increase the likelihood of family-focused approaches being incorporated. Research should also investigate whether there is an underlying component underpinning perceived skill and knowledge, impact of training, and length of service in order to more directly and efficiently instigate FFP. Future research should also focus on developing available resources for adult mental health services, which would help in facilitating practitioners' assessment practices and the support they can offer when meeting with clients accessing their services. Longitudinal studies are also required to examine the impact of influential factors on FFP over time to help ensure that efforts to incorporate more family-focused approaches in services can be sustained.

CONCLUSION
The factors most consistently found to influence the family-focussed practice of adult mental health practitioners were personal attitudes, beliefs about job role, and perceptions of workplace support. Other factors are also likely to impact FFP, but further research is needed to ascertain what these are and how they influence FFP. In order to increase understanding of the interplay of parenting stressors and the reciprocal impact upon mental health, efforts need to be made to enhance practitioners' knowledge and confidence around FFP. Enhanced competency can be achieved via specific, family-focused education and training, but also at an individual team level through discussions about job role and remit. Such service-development discussions could involve ascertaining whether certain professions lend themselves to leading on certain aspects of FFP, with the explicit understanding that being able to incorporate family-focused approaches is fundamental to working with adults with mental health difficulties. Similarly, increasing opportunities for workplace support is integral in facilitating FFPthis needs to be at both a managerial and colleague/peer level, and can include more formal sessions, such as supervision and multi-disciplinary team discussions, as well as more informal exchanges, such as debrief sessions and frequent consultation.

Relevance to clinical practice
The current review offers updated, targeted, evidencebased recommendations about how efforts to encourage FFP in adult mental health services might best be applied. These findings can be used to inform policy development and service delivery, as well as the direction of future research, and in doing so contribute towards helping overcome the challenges faced by families affected by parental mental illness.

FUNDING
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