Developing a Family-Based Depression Prevention

Program in Urban Community Mental Health

Clinics: A Qualitative Investigation
RHONDA C. BOYD, PH.D.w
GUY S. DIAMOND, PH.D.w
JORETHA N. BOURJOLLY, PH.D.ww

Extensive research documents that children of depressed mothers are at a significantly higher risk for developing a variety of socioemotional difficulties than children
of nondepressed mothers. Yet, little prevention research has been conducted for this
population, and low-income, minority, and urban families are rarely included. To
address this deficit, we are developing the Protecting Families Program (PFP), a
family-based multicomponent depression prevention program for mothers in treatment
at urban community mental health agencies and their school-aged children. To inform
intervention development and begin relationship building with the agencies, patient
and staff focus groups were conducted in the participating agencies. Eighteen mothers
with depression participated, and eight major themes were identified: (1) depression
symptoms, (2) generational legacy, (3) parenting difficulties, (4) child problems, (5)
social support, (6) stressful life events, (7) therapy and other helpful activities, and (8)
desired treatment. In the focus groups with 10 mental health providers, the five major
themes identified were parenting difficulties, lack of social support, life stress, current
mental health practices, and intervention development. The findings support the
multicomponent design of PFP, which focuses on increasing knowledge of depression,
enhancing social support, and improving parenting skills. The study helped clarify
many of the challenges of conducting research in a community mental health system.
Keywords: Intervention Development; Prevention; Depressed Mothers; Ethnic Minorities
Fam Proc 45:187203, 2006
wUniversity of Pennsylvania School of Medicine/Childrens Hospital of Philadelphia, Philadelphia, PA.
wwUniversity of Pennsylvania School of Social Policy & Practice, Philadelphia, PA.
The work described in this article was supported by grants from the W.E.B. DuBois Collective Research
Institute at the University of Pennsylvania and from the National Institute of Mental Health (R34
MH071868 and K01 MH68619). We would like to thank Alicia Veit, Gary Colin Emerle, Michelle Kahn,
Suzanne Levy, Halerie Mahan, Natashia Robbins, Jameika Sampson, and Anastasia Zyuban for their research assistance.

Correspondence concerning this article should be sent to Dr. Rhonda Boyd, Department of Child
and Adolescent Psychiatry, Childrens Hospital of Philadelphia, 3535 Market Street, Suite 1230,
Philadelphia, PA 19104. E-mail: rboyd@mail.med.upenn.edu
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INTRODUCTION
Extensive data indicate that the offspring of depressed mothers are at high risk for
psychological maladjustment and psychiatric disturbance into adulthood (Goodman,
& Gotlib, 1999). Families living in low-income urban neighborhoods are a particularly
vulnerable group because of the higher rates of depression and the stressful context of
their environments (Belle & Doucet, 2003). Ethnic minorities are overrepresented in
low-income urban neighborhoods and are faced with particular psychosocial stressors
that may threaten family and individual functioning. Given the serious consequence
of depression in adolescents and adults, efforts at preventing this disorder in high-risk
populations deserve more attention.

Risks of Children of Depressed Mothers

Compared with children of nondepressed mothers, children of depressed mothers
have an increased risk of childhood major depression disorder, anxiety disorders (i.e.,
phobias, panic disorder), and conduct disorder (Weissman, Warner, Wickramaratne,
Moreau, & Olfson, 1997; Wickramaratne & Weissman, 1998), and a high rate of comorbidity of these disorders (Warner, Weissman, Mufson, & Wickramaratne, 1999).
Weissman et al. (1997) showed that the peak age for greater incidence of MDD is
between 15 and 20 years. These children have difficulty regulating their behavior and
emotions (Tronick & Gianino, 1986; Zahn-Waxler & Kochanska, 1990) and interacting
with peers (Goodman & Gotlib, 1999). They report less self-worth, greater self-criticism, more negative cognitions (Garber & Robinson, 1997), and higher levels of insecure attachments, both avoidant and disorganized, to their depressed mothers
(Martins & Gaffan, 2000).

Low-Income and Ethnic Minority Families

Low-income families are a particularly vulnerable group because these mothers
have increased rates of depression (Belle, 1990) and face the additional pressures of
financial and psychosocial stress, both of which negatively affect parent-child interactions (McLoyd, 1998). The high incidence of depression, attachment difficulties, and
posttraumatic stress has been found to undermine impoverished mothers ability to
provide sufficient structure, empathy, and responsiveness to their childrens needs
(McLeod & Shanahan, 1993; McLoyd). Distressed low-income women perceive
parenting as more difficult and engage in fewer nurturing behaviors with their children than low-income mothers with less psychological distress (McLoyd & Wilson,
1991).
In particular, ethnic minority women and their children are confronted with a host
of environmental factors that are stressful and that likely increase their vulnerability
to depression (Brown, Abe-Kim, & Carrio, 2003). Contextual factors, such as poverty,
residence in inner-city environments, exposure to violence, and racism, are commonly
experienced by African Americans and Latinos (U.S. Department of Health and Human Services, 2001) and can have profound impacts on maternal and child functioning. It has been suggested that maternal depression affects parenting when ethnic
minority mothers have limited personal resources and greater contextual stress
(Murry, Bynum, Brody, Willert, & Stephens, 2001).
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Interventions for Children of Depressed Mothers

Surprisingly, few efforts have been aimed at preventing or treating the psychological problems of children whose mothers are depressed, who are ethnic minorities,
and who live in impoverished and urban environments. Of the programs that do exist,
many target mothers with infants or very young children (e.g., Cicchetti, Rogosch, &
Toth, 2000; Clark, Tluczek, & Wenzel, 2003; Field, 1998; Gelfand, Teti, Seiner, &
Jameson, 1996). Others have focused on school-aged children and adolescents using
mostly cognitive behavioral therapy (CBT) and/or psychoeducational interventions
(Beardslee et al., 1997a, 1997b; Clarke et al., 2001, 2002; Sanders & McFarland, 2000).
Only one study, a modification of Beardslee and colleagues cognitive psychoeducational preventive intervention (Podorefsky, McDonald-Dowdell, & Beardslee, 2001),
has focused specifically on a low-income ethnic minority population.
Given the potential consequence of maternal depression on children and the increased risk of poverty for low-income urban families, preventive interventions that
specifically target this population are warranted. To address this need, we have obtained an intervention development grant from the National Institute of Mental
Health to design, manualize, and empirically test the Protecting Families Program
(PFP), a 10-week family-based multicomponent prevention program for depressed
mothers and their school-aged children (ages 914). PFP targets low-income urban
children whose mothers are in treatment for depression at community mental health
clinics. Each session begins with a community meal that serves to build relationships
and social support between participating families. After the meal, mothers participate
in a 90-minute parent training program that (a) provides psychoeducation about depression, its impact on children, and child development, and (b) teaches parenting
skills that can improve childrens affect regulation and behavioral control. Concomitantly, children participate in a cognitive-behavioral group (Penn Optimism Program
[POP]; Gillham, Jaycox, Reivich, Seligman, & Silver, 1990) that teaches cognitive
restructuring and coping skills. Also included in the program are some individual
family sessions in which there is an opportunity to discuss the impact of the depression on the family. This interaction builds on the skills and context of the group
training sessions. A full presentation of the intervention model is premature given
that we remain in the program development phase. Instead, we present here some
lessons learned about the culture of both depressed low-income urban mothers and
the community mental health centers within which they seek services.
To reduce many of the implementation challenges that arise when exporting
empirically validated interventions to real-world clinical settings (Hohmann &
Shear, 2002), we are developing the PFP program in collaboration with the patients
and staff at the community mental health clinics where the intervention will be tested
and, we hope, used. To facilitate this collaborative process, we have incorporated
qualitative research methodologies into our work. Qualitative investigations allow
researchers to hear directly from the consumers and providers about their treatment
needs, desires, and barriers. In addition, it provides insight into the dynamic system of
family, agency, community, and culture that shapes the lives of all involved (Pescosolido, 1991). Specifically, we used a focus group methodology with both the depressed mothers and mental health providers at the community mental health
agencies. For the patients, focus groups help researchers gain insight into the phenomenological, day-to-day strengths and challenges of the subjects lives. They also
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encourage investigators to respect the participants as experts about their own experience. For the providers, these groups helped engage them in the project and offered
an opportunity for their input on the program. In this regard, the focus groups empowered the primary stakeholders as project collaborators and helped us join with and
become more integrated into these systems. In this article, we present the focus group
findings and discuss critical challenges in developing a research prevention program
within urban community mental health centers.

METHOD

Sample Characteristics
Eighteen mothers who receive treatment at one of two community mental health
agencies participated in six focus groups. The number of participants in the groups
ranged from 2 to 5. The number of children for the participants ranged from 1 to 6,
with a mean of 2.67 (SD 1.03). The womens ages ranged from 22 to 58 years, with a
mean of 43.06 (SD 9) years. Racial/ethnic composition was as follows: 67% African
American, 28% White, and 5% Latino. Forty-four percent of the women describe
themselves as single, 40% as widowed, divorced, or separated, and 17% as married.
After the focus groups were conducted, diagnoses were requested from the community
mental health agencies. Primary diagnoses provided from the medical charts were as
follows: major depressive disorder (3), major depressive disorder with psychotic disorder (3), depressive disorder (1), dysthymic disorder (1), schizophrenia disorder (2),
neurotic depression (1), bipolar depression (1), adjustment disorder with depressed
mood (1), adjustment reaction with emotion features (1), and acute schizophrenia
episode (1). Only one agency provided secondary Axis I diagnoses, and these included
dysthymic disorder and anxiety disorders (generalized anxiety disorder, panic disorder without agorophobia, and anxiety disorder, NOS). This was not a diagnostic study,
so structured screening for psychiatric diagnoses were not employed to corroborate
the clinics diagnoses of the patients. In general, the participants met criteria for
depression based on the clinic records. This sample can also be characterized as
chronically depressed women who likely have been in treatment in community mental
health for a number of years.
Ten mental health providers from the adult services division at two community
mental health agencies participated in two focus groups. Four providers participated
in one group and 6 participated in the other. Sixty percent of the mental health
providers were women. Ninety percent identified as White, and 10% identified as
African American. Thirty percent had doctorate degrees, and 70% had masters degrees. Clinical experience ranged from 1 to 23 years, with a mean of 10.80 (SD 6.37)
years.

Inclusion and Exclusion Criteria

Inclusion criteria required each patient to have a depressive disorder as a primary
diagnosis, to be in treatment at the community mental health agency, and to have a
school-aged child living with her at least part time. Exclusion criteria consisted of
current substance dependence, psychotic disorder, and mental retardation. Initially,
bipolar disorder was an exclusion criterion, but the staff at one agency said that this
was the predominant diagnosis for patients with mood disorders. Therefore, to work
within the culture of the agency and to assure that we met our recruitment goals, we
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expanded our inclusion criteria to include patients with a mood disorder as long as
depression played a prominent role.

Agency Characteristics
Focus groups were conducted at two community mental health agencies through
their adult services division. One agency services individuals from diverse racial and
cultural backgrounds in the lower and lower-middle socioeconomic levels, while the
other services individuals who are mostly African American and of low socioeconomic
levels.

Recruitment
At staff meetings of both agencies, we presented an overview of the research program and focus group procedures. The goal was to introduce ourselves, to begin
gathering information about patient referrals from staff, and to recruit agency providers to participate in the provider focus groups. For patient recruitment, providers
were given a flyer and asked to approach their eligible patients about the study. Interested patients would sign a release allowing us to follow up with a recruitment
phone call. Follow-up phone calls were infrequently done by the research team because agency staff preferred to do it themselves. For example, at one agency, the clinic
director personally mailed the flyer to all identified patients with depression and
children, and then followed up with a call. Focus groups were scheduled based on dates
and times recommended by the staff, and the staff were responsible for inviting
participants to the scheduled focus groups. With one clinic, two focus groups were
cancelled because of too few participants.

Focus Group Procedures

Each focus group was conducted on site and lasted approximately 60 minutes. Staff
were provided lunch, and mothers were provided refreshments, compensated $25, and
if needed, provided bus tokens and child care. Each focus group was audiotaped and
moderated by the primary author (R. Boyd). Written consent was gathered by the
moderator for each individual participating in the focus group. This study was approved by internal review boards at the Childrens Hospital of Philadelphia, the
University of Pennsylvania, and the Philadelphia Department of Public Health.
Several topical questions guided the discussion in each focus group. However, we
did not use a tightly structured approach because we wanted to gain new ideas about
the patients and observe their interactions with each other (Koppelman & Bourjolly,
2001). The core questions for the patient focus groups were (1) What is the impact of
depression on your parenting? (2) How has your family coped with depression? (3)
What are your concerns about your children? (4) What obstacles and/or stresses make
it difficult for you to deal with depression and parenting? (5) What resources assist you
in dealing with depression and parenting? (6) Are there areas in your parenting and
family that you could use additional assistance? (7) How has attending [community
mental health clinic] impacted your parenting? and (8) If [community mental health
clinic] provided a program for parents like you and your children, would you attend? If
so, what would you hope to get out the program? Similar questions were posed to the
mental health providers about their depressed patients.
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Qualitative Data Analyses

The audiotape of each focus group was transcribed, and the transcripts were then
checked against the audiotapes. Written notes were taken during each focus group
interview, and these notes were also used as needed in the transcription process.
During transcription and correction, personal names and identifying information
were removed. A multiphased process was used to analyze the transcribed interview
data based on content analytic methods (Miles & Huberman, 1994). Three coders
coded each transcript independently; the primary author (R. Boyd) coded all the
transcripts. The coders completed open coding of units of analysis. Next, they identified initial categories and engaged in comparative analysis. At least two of the three
coders were in agreement for an initial category to be identified and recorded. The
core themes were identified through consensus and represented the categories identified in the majority of the focus groups. Finally, the initial sets of categories were
reorganized around these core themes.

RESULTS

Mother Focus Groups

The mother focus groups identified eight major themes: (1) depression symptoms,
(2) generational legacy, (3) parenting difficulties, (4) child problems, (5) social support,
(6) stressful life events, (7) therapy and other helpful activities, and (8) desired
treatment. Each is discussed briefly next.
Depression symptoms. A common theme was the discussion of depressive symptoms,
such as irritability, sadness, hopelessness, suicidal attempts, fatigue, withdrawal, and
anxiety. One parent said, Its hard . . . If I am real tired, depressed, I dont want to get
up and I dont want to do nothing . . . I just want quiet. Another parent remarked,
If I am depressed when they [children] come home and . . . have a lot of homework . . . I cant
help them. It makes me feel emotional, and its hard on them because they need the help. But
I cant really concentrate on helping them with the homework.

One mother summed it up by stating, Being depressed . . . wears you down. It takes
a lot of work.
Generational legacy. The depressed mothers commonly talked about the relationships
with their mothers in the past and the present, many of which have been conflictual.
Several had mothers with mental health problems. One mother said,
My mother was schizophrenic and growing up with her, seeing her laying around all the time
and not really participating in our upbringing. She was a good mother given her illness . . . . It
really hurt me to see her ill and I dont want my children to feel that way about me. I was
afraid that I would wind up like her.

Some of the mothers talked about verbal and physical fighting among family
members, such mothers with their own mothers and siblings, and among the children.
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sion] around them. Cause I want them to be happy. I dont want them to live how
I live. So I try not to show it, but they know it . . . they know something is wrong.
Parenting difficulties. The mothers noted their problems with parenting, such as
inconsistent discipline, overprotectiveness, constantly feeling frustrated, lack of patience, lack of control, and parentification of children. One mother stated,
My son knows how to give me my medicine when I dont feel like it and Im tired and Im sick
of taking that medicine. . . . He gets it all . . . he go in the refrigerator, gets water, gets the
pills, gets me a needle cause Im a diabetic.

One mother described a recent argument with her pregnant teenage daughter:
She was banging doors and throwing stuff down the steps . . . I am tired of calling the
cops cause when they come out they would say, they are your children . . . Its hard. I
am a single parent with five in the house. Sometimes these parenting difficulties
result in extended family taking over the care of the children. One mother said, I
really wanted my mothers to take the children, just finish raising them. But they saw
what I was doing and they said were here to support you, but these are your children.
Child problems. Not all the mothers reported behavioral or emotional problems in
their kids. Of those who did, the problems consisted of depression, attention deficit
hyperactivity disorder (ADHD), drug abuse, learning disabilities, medical conditions,
lead poisoning, school difficulties, and legal issues. ADHD and learning disabilities
were commonly reported. One mother stated, My son . . . hes still depressed, and Im
trying to help him and Im depressed. So Im fight[ing] two battles. Mothers reported
these child problems as a great source of stress.
The mothers whose children had mental health problems talked a great deal about
the childs treatment. Children were in special education programs, individual therapy, family therapy, partial program, and wrap-around services. A few of the children
had been hospitalized. Some of the mothers entered treatment as a result of their
childrens involvement in treatment. One mother commenting on her daughters
therapy said, She likes to talk. And she says when she comes here [community
mental health center] she feels better . . . I see it in her.
Social support. Social support was a pressing theme for the mothers in the focus
groups. Some mothers have support from family members, spouses, and friends. The
support can be emotional or physical and may consist of having a confidante, people to
check in on them, and assistance with childrearing and housework. One mother said,
My daughters grandmother or my mom would come get the kids so I could have
some time to myself, to gather my thoughts and try to push for more goals instead of
just sitting around the house sleeping and being depressed that I dont have a job.
Regarding spousal support, one mother stated, My husband really helps because he
helps me clean and cook and when Im ill, he takes over for me.
Other mothers lack social support, and this exacerbates their loneliness and depression. One mother commented, Ive only had one hospitalization and my mother
was the last person I told because shes not very supportive. Several mothers stated
that they had no friends. Even though mothers may have supportive relationships,
they often feel that people misunderstand their depression. One parent said, You
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dont talk about that [depression], thats taboo, you suck it up. Another mother was
told by her father, the money you are spending for therapy, you could take that
money and go on vacation . . . just a change of scenery. The mothers felt that their
fatigue and need for solitude was often viewed as laziness and self-indulgence. A few of
the married women discussed strained relationships with their spouses, incarcerated
spouses, or conflicting working schedules. The single mothers complained about
raising children alone. One woman remarked, Im too young to be going through this
with three boys. Their dads are not around. Their dads are not in their life. Where can
I get help?
Stressful life events. The mothers identified numerous life stresses that impacted
their families lives, such as financial strains, violence, housing problems, and trauma.
One mother stated,
You dont have enough money to buy them what they want, it hurts when your kids see
their friends getting something new and they want it and you dont have it . . . because
youre trying to make sure theres a roof over their head, food on the table, lights . . . and
heat.

Another mother remarked,

Its hard . . . the cops were on our corner everyday because the drugs got that bad but . . . the
neighborhoods fine now . . . the boys dont hang on the corner no more. But the drugs still
there . . . one boy got killed. The boys [was] dead in front of my house.

Therapy and other helpful activities. For many mothers, mental health services were
viewed as the most helpful activity that they participated in. Individual counseling,
group therapy, and medication were all viewed as beneficial. Specific benefits
include social support, knowledge provided by therapists, and help with stress. Some
mothers viewed mental health treatment as a temporary relief. Opinions were
mixed about how mental health treatment impacted parenting. One mother stated, I
feel good after I come from therapy to go deal with my son. He dont get on my
nerves that bad. Regarding to group therapy, one mother said, I would like to sit
around and just listen to other peoples situations and see how they handle theirs. And
just get some kind of knowledge from them. Maybe theres something the people [are]
doing that Im not really doing. Another mother commented, They care. They sit
there and listen to you. . . . You get some of your frustrations out. . . . It dont help you
as far as being a parent cause once I leave, all that I went through [is] coming
right back.
Other activities were mentioned that help the mothers cope with depression and
parenting. These included pampering oneself and having outlets, such as poetry
writing, watching movies, and listening to music. Religious activities, such as attending church and praying, were also noted as helpful. One mother remarked,
Church has been really help for my children and myself even when I felt awkward
and uncomfortable about going to service I could see my children involved with their
peers in the choir and I was grateful for that. . . . Church has definitely been a support
system for the children. Physical activity and exercise were also mentioned as giving
benefit to the mothers.
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Desired treatment. The mothers were enthusiastic about attending a program with
their children. Many of the mothers noted that their families could benefit from being
with other families in similar situations. The mothers identified program areas of
interest, attendance barriers, and incentives to aid attendance. Mothers stated that
they wanted to improve their parenting and that they and their children needed to
learn more about depression as a disease (psychoeducational training). The mothers
also indicated that they were interested in learning about substance abuse and in
obtaining practical skills (e.g., computer skills). The mothers also said that they would
enjoy having positive and enjoyable family activities in a comfortable environment.
Barriers to attendance included time constraints with school schedules, older children
refusing to attend, embarrassment, and juggling many demands. Incentives included
transportation, food, and child care.

Mental Health Provider Groups

The mental health provider identified five major themes: (1) parenting difficulties,
(2) lack of social support, (3) life stressors, (4) current mental health practices, and (5)
intervention development. Each is discussed briefly.
Parenting difficulties. The mental health providers described depressed mothers as
having several deficits in their parenting skills, including emotional liability, impatience, and inconsistency. For example, one provider said, Theyre . . . taken over by
the depression. And not able to . . . be there for their kids. Many providers discussed
how mothers irritability intruded on parenting. As stated by one provider, Others
[mothers] talk about being so irritable. Yelling at kids. Whatever theyre [the children] doing . . . is magnified into a giant transgression. Providers also described how
the depressed mothers withdraw from interacting with their children and physically
isolate themselves in their rooms. Finally, many providers felt that these mothers had
difficulty disciplining and enforcing rules for their children.
Lack of social support. Lack of social support was identified as an area of critical
concern for these clients. This was evident for single, married, or coupled mothers.
The providers viewed the lack of social support as exacerbating the depression
symptoms and making parenting more burdensome. One mental health provider said,
My clients husband works, at night . . . shes got them [the children] till bedtime . . .
shes overwhelmed and depressed, and that contributes to the irritability. Another
providers statement echoed the need for social support for the mothers: [Shes a]
single parent . . . theres no like back-up there for her.
Life stressors. Providers described the overarching financial and community stressors
faced by these mothers. Financial stress included impoverished conditions, unemployment, and housing needs. Neighborhood concerns included community violence,
drug trafficking, poor schools, and few community resources.
Current mental health practices. The providers were asked about the mental health
services that they provide for their depressed patients with children. Consistently,
providers expressed that the adult patients treatment focused on the patient as an
adult without a great deal of attention to the patient as a parent. For example,
one provider said,
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What I see in the people I see [patients] is that I spend more time working with them and the
issues they have than I do with child rearing issues. They [parenting issues] may come up
from time to time, but theyre not the major thing that we work on.

Providers also described themselves as lacking the experience, knowledge, and

qualifications to help with parenting and the parent-child relationships.
Providers were also asked if the children were receiving mental health services;
the providers reported that some were and some were not. As one provider
described,
Well some of mine [patients] are really good at getting the help they need . . . some of them
had TSS [therapeutic support staff] workers with their kids. A lot of them have had their kids
seen here [community mental health center]. A couple of them have been in the school
programs that we have here.

Providers expressed mixed feelings about the usefulness of these services. One
provider stated, Unfortunately . . . a lot of mothers look at wraparound as respite. Its
not respite. Most surprising was that most of the providers (i.e., therapist providing
adult services) had limited knowledge about the types of services available to children,
even at their own agency.
Intervention development. The discussion on the development of a parenting
intervention for depressed mothers focused on the barriers to implementation
and program structure and content. The single major barrier identified was low
motivation to attend treatment, resulting in poor attendance. Although this is
a problem for many clients in community mental health programs, providers felt
this was particularly problematic for depressed clients, who tended to be more isolated
and withdrawn. As one provider stated, I think that the lack of motivation is
a big issue with depressed mothers. Its hard enough to get them to come for
[an] individual session. Many providers felt that addressing some of the logistical barriers (e.g., transportation, food, and child care) might reduce some of
the psychological barriers (e.g., poor motivation, hopelessness, helplessness).
Because mothers may work and children were in school, an evening program was
encouraged.
In terms of program structure and content, most providers felt that a
multifamily group program was ideal. Providers believed that this structure
could allow for mothers and children to gain support and learn some skills while
also interacting with other families. Providers also recommended that the program
be on-site at the community mental health clinic, a place where mothers already
felt comfortable (as opposed to bringing them to the university or hospital
setting).
The providers were clear that the intervention should provide education about child
development and that parent skills training should be emphasized in a practical and
goal-oriented manner. One provider suggested focusing on bed time,
specifically that they [their] kids arent going to stay up until 1 oclock in the morning . . .
their bedtime is going to be 8:30 or 9 oclock . . . and that would be the goal for the group . . . so
they can see hopefully some specific outcome that will give them some hope that things can
change.

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DISCUSSION
The purpose of this study was to obtain qualitative data to inform the development
of a family-based depression prevention program for parents receiving services in
urban community mental health centers. Focus groups were conducted with mothers
and mental health providers in these agencies to ascertain if there were parenting and
service delivery issues specific to depressed mothers and how a research-based intervention model might fit within a community mental health center. Based on the
focus group findings, it may be striking that the mothers did not discuss more depression specific experiences. In particular, the mothers did not seem to make a direct
link between their depressive symptoms and their potential impact on parenting and
interpersonal functioning. This is surprising given the often recurrent course of depression. Additionally, although the majority of the participants were African American, race and cultural issues did not emerge within the groups. This may have
occurred because we did not specifically ask about it. The mothers used the focus
groups to tell their personal stories. What appeared most poignant were their day-today struggles and chronic stressors that are common to other women living with
economic disadvantage and/or with psychiatric problems.
The findings demonstrate that many mothers in our study were dealing with a host
of common problems faced by mothers in this community: managing their childrens
behavior, protecting their children from unsafe neighborhoods, concern over their
childrens psychiatric distress and school problems, lack of social support, and lack of
resources. These findings are consistent with Nicholson, Sweeney, and Gellers (1998)
focus group study involving mothers with a variety of mental disorders who were
receiving case management. The majority of the sample in the Nicholson et al. study
had an affective disorder, received public assistance, and was White. In that study, the
mothers also focused on the challenges of parenting among stressful life conditions.
Possibly, raising children in an urban environment with limited resources can be
more salient than having depression or being of a certain racial/ethnic group.
Nevertheless, some of the findings were likely specific to depression. The irritability, anhedonia, and lethargy clearly compromise the energy and consistency needed
to carry out the already challenging task of parenting. In addition, depression reinforces social isolation that leaves a mother feeling alone, with few people to turn to for
support, encouragement, and help. This was consistent with research that suggests
that depressed adults report more conflictual relationships and social isolation than
nondepressed adults (i.e., Coyne et al., 1987; Hammen, 1991).
Depressed mothers are also more likely to be distracted and preoccupied (Campbell,
Cohn, Flanagan, Popper, & Meyers, 1992) and exhibit more irritability and intrusiveness with their children (Field, Healy, Goldstein, & Guthertz, 1990). In observational studies, depressed mothers are more punitive, negative, and retaliatory, and
engage in more angry, hostile, and conflictual behavior (Field et al.; Hammen, 1991).
Compared with nondepressed mothers, depressed mothers are ineffective in resolving
problems and alternate between overly harsh punishment and lax or indifferent behavior (Dumas, Gibson, & Abidin, 1989; Kochanska, Kuczynski, Radke-Yarrow, &
Welsh, 1987). In one of the few studies of low-income, single African American
mothers, Goodman and Brumley (1990) characterized depressed mothers parenting
as limited in both structure and involvement with their children as compared with
nondepressed mothers.
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Yet, these parenting deficits have also been noted with mothers with psychopathology and serious stress, such as poverty. Lyons-Ruth, Lyubchik, Wofle, and
Bronfman (2001) theorized that depressive symptoms serve as a correlate to parenting
deficits and are not a primary causal factor. In fact, maladaptive family interactions in
the family of origin may serve as the primary contributor to both depression in the
mothers and their negative parenting with their children. Our mothers in the focus
groups described conflict with their parents and siblings and its continued impact on
them.
Overall, the focus groups findings confirmed that our program design might be
appropriate for the population in community mental health. Certainly the providers
thought that multifamily group could not only be an effective modality for treatment
but also that it would help counter the social isolation characteristic to this population. In addition, the providers agreed that the community meal, child care, and
transportation would greatly assist a population that traditionally has a hard time
attending treatment. These incentives to reduce barriers are not typically provided in
community mental health treatment. Finally, the mothers seem to welcome an opportunity to have a positive and meaningful experience with their children.
The focus groups also helped us think about engagement in the prevention program. The diagnostic picture of depressive disorders, unlike, say, substance abuse,
reinforces withdrawal and hopelessness. Therefore, we have designed two initial individual sessions, first with the mother, and then with the whole family. These will be
alliance-building sessions that could help transition the mothers into the group, a
modality that may present some challenges and benefits for depressed mothers. We
will also use these sessions to help the family begin the potentially awkward conversations about the mothers depression. Other investigators (Beardslee et al., 1998;
G. Diamond, B. Compass, M. J. Coiro, C. Valdez, & A. Riley, personal communication,
September 16, 2005) have indicated that facilitating this conversation can be an important element of the intervention model. These initial sessions will also allow us to
gather more information concerning how race, ethnicity, and culture are expressed
within each family. This will inform the family activities during the community meal
and in choosing examples and illustrations within the parent and child groups.
Education about depression emerged as an intervention component that would be
beneficial to mothers and children. In Beardslee and colleagues (1997a, 1997b) cognitive psychoeducational intervention aimed at families with a parent diagnosed with
unipolar or bipolar disorder, the sessions are designed to increase parents knowledge
about symptoms and causes of childhood and adult depression and to provide information about how to foster resiliency in children. Ideally, this knowledge will help
mothers feel more empowered to manage their depression and their childrens behavior instead of feeling like victims of their depression and incompetent as mothers.
The outcome studies of the cognitive psychoeducational intervention showed improved family communication about and understanding of affective disorders
(Beardslee et al., 1997a, 1997b; Beardslee, Gladstone, Wright, & Cooper, 2003).
There was certainly support for a parent-skills-training component of the intervention. Mothers in our focus groups expressed difficulty in parenting behaviors, especially as it related to their depression. A parent-training component to a prevention
program can help mothers to create a safe and predictable environment for their
children and identify positive ways to engage cooperation and deal with noncompliance. Parent training can teach behavioral management skills based on the rich
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literature in this area (e.g., Barkley, 1981; Forehand & Long, 1988; Patterson, Dishion, & Chamberlain, 1993) that can be used to counteract the inconsistency, limited
structure, and critical interactions that can characterize families with depressed
mothers. These skills may also help mothers ease their own depression by building
structure and routines for themselves and fostering a sense of competence and effectiveness as mothers. Nevertheless, it is important to teach parenting skills in a
manner that is congruent with the mothers cultural values of parenting and raising
children. We have put much consideration into not making the mothers feel worse
about their parenting. We are expecting to present the parenting skills as a way to
increase the mothers repertoire of skills that can be used for managing childrens
behavior and interacting with children. We will reinforce and model these parenting
skills during the community meal. Because the majority of our mothers are single, we
anticipate addressing how these parenting skills work in a female-headed household
or in coparenting situations, which may include the childs father, the mothers significant other, or grandparents who are assisting in raising the children.
As a result of the focus groups, we are developing a parenting session focused on
social support. Although most mental health prevention programs do not seek to
impact poverty itself, interventions focused on social support, self-efficacy, and
problem-solving skills are recommended to help buffer against the stressors associated with poverty (Beardslee & Podorefsky, 1988; Green & Rodgers, 2001; Hammen,
2001; Masten & Garmezy, 1985). Social support has been shown to buffer the effects of
community stress (Wandersman & Nation, 1998) and has been successfully included
in other prevention programs (e.g., Zlotnick, Johnson, Miller, Pearlstein, & Howard,
2001). Mothers in the groups clearly expressed an interest in increasing the level of
social support, and we have responded to this with a session devoted to it. It is important to note that many of the mothers did not acknowledge their childrens fathers
as sources of social support, which would be particularly difficult for mothers raising
children alone. Based on the mothers comments, we thought that the social support
session would include how to foster and garner social support among family, friends,
and agencies. Social support is expected to increase during the parenting group and
the community meal. To adapt to the culture of the population, we recognize that the
family network will likely include extended family members, fictive kin, neighbors, or
church members. With this view of family, we plan to work with the mothers on how to
best access and use those in their family network for social support. In addition, the
session will teach mothers how to be advocates for themselves and their families.
Many of the women seemed to feel too powerless and overwhelmed by the tasks to get
them and their children the services that they required, such as navigating special
education services in the school.
In the revision of the POP, we are planning to include examples and exercises that
pertain to life experiences of urban children living with a depressed mother. In the
focus groups, the mothers described situations that we could use as examples, such as
a mother being too fatigued to take a child to a school athletic event or to help her
children with their homework. To address the cultural aspects, we will use the innercity version of the POP (Cardemil, Reivich, & Seligman, 2002), which was revised for
urban African American and Latino school children and uses examples, situations,
pictures, and language consistent with the population.
There were several limitations to this study. The sample size was small, and no
fathers participated in the focus groups. Information about socioeconomic status for
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each mother was not collected. The focus group interview did not specifically ask
about race, ethnicity, or culture. Unfortunately, the patient focus groups do not
contain adequate representation of mothers who were receiving medication treatment
only. Additionally, the categories generated from the focus group transcripts were not
subjected to a validity check. Getting an accurate diagnosis was challenging. It was not
uncommon for a patients diagnosis to differ among the intake, the providers, and the
patients description. As a result of this discrepancy, we will conduct structured
clinical interviews for the intervention trial. Finally, mental health providers invited
their clients to participate in the group, and thus they may have invited those who
were more verbal or who were benefiting from therapy.
In addition to learning about the depressed mothers and their treatment, the focus
groups provided an opportunity to learn about conducting research in a community
mental health agency. Typically, administration is very interested in collaboration
with the university while the clinical staff often feel burdened by the research,
which might ask them to change their practice or do additional tasks to conduct the
research. In addition, some structural challenges exist. For example, the centers
struggled with how to bill for the services provided in a research project and the liability issues if the child involved in the preventive intervention is not a formal patient
of the agency. Clearly, the biggest challenge was balancing internal validity versus
generalizability. This was most evident when deciding on the inclusion criteria. Most
providers were skeptical about finding enough patients with only a depression diagnosis. The general consensus was that most patients struggled with bipolar disorder,
substance abuse, or a variety of psychotic disorders. As mentioned, we had to expand
our criteria to meet our recruitment goals and to design a program relevant for
community mental health clinics.
On the other hand, there are several advantages to developing a preventive intervention within a community mental health agency. The PFP is being developed in
collaboration with community mental health staff and will be implemented and tested
in the community. The development of PFP is unique in that it incorporates both
efficacy and effectiveness research. The intervention is being designed to fit into the
community mental heath system with buy-in from staff and patients at the centers.
Sustainability of the program once the research is completed is more likely because
staff will be involved in the development and delivery of PFP. Finally, PFP fills a gap
in the treatment of depressed mothers in that the program focuses on their role as
a parent and provides CBT skills to their children to prevent the intergenerational
transmission of psychopathology.
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