Table 5.

Themes, descriptions, and quotes

Theme	Description	Quote
Topic 1: Perceived benefits outcomes and change mechanisms
1. Learning, knowledge, and skill development
1.1 Increased knowledge and understanding of mental illness	Psychoeducation and mental health literacy components of interventions helped increase parent and children’s knowledge of mental health problems affecting their family and the potential impacts of mental illness on the family. This led to increased understanding of family member’s experiences of PMI. In group settings, the sharing of experiences and advice also provided additional knowledge and understanding	“I wanted him to be able to have an understanding... the signs of what to look out for, not even in myself, but say for his peers, amongst him and what have you and even himself... I was willing to give it a go and what have you, for the simple reasons, I wanted [my child] to have a bit of an understanding as to why I can be like the way I am.” (W16P16A1, ID-n:10)
1.2 Coping skills development	Both parents and children reported developing coping skills in how to deal with the impacts of PMI. This included general coping skills, increasing well-being and self-esteem and for children developing ways of dealing with school problems (e.g. concentration). Children also reported learning who to turn to when they needed support with PMI and learning how to respond to parental mental health problems	“When we know she’s becoming ill, we kind of bring up strategies and things, you do this, you do that, and if you don’t do this she’s going to … you know, we have to talk about it, yes, definitely. So we’re both happy to talk about it, but talking about it to my mum.” (Young person past attendee, ID-n: 59) “I can’t really change [my parent], I have to learn to live with that... getting on with my life and not letting [my parent’s] problems affect me…I don’t want it to get me down, I’ve got a sense that I can get on with my life without letting it worry me.” (Child, ID-n: 79)
1.3 Parenting skills	Change in parenting skills and confidence in skills Parents reported learning practical parenting skills to support their interactions with their child and feel more confident in their parenting skills	“Being able to try out such a reward system for a bit, or simply implementing certain parenting strategies that I’d heard of before in theory but just never really officially tried out." (Parent of family 5, ID: 16)
2. Enhanced family environment and relationships
2.1 Family relationships	Interventions improved family bonding, relationships (parent–child, couple and sibling) and cohesion at home. Shared activities and sharing experiences in the interventions led to more of these activities at home as well. This was seen to lead to healthier family dynamics and a shift in roles and responsibilities	“I have a better understanding of how my mum feels... [which has made their relationship] a lot better because we’re getting along a lot better now... We’re not arguing anymore.” (W01Y02A1, ID-n: 10) “... it brought us closer together so we can bond... a bit more, cos normally I’m out just playing with my mates and [my brother’s] out with his mates and mum’s in her room, now mum comes out of her room we all sit down downstairs, watch TV, eat dinner together, which we never used to do before.” (Child; ID-n: 79)
2.2 Communication	There were mixed responses about how interventions had improved family communication. For some, communication had improved (around PMI and in general), reducing the level of conflict in the home. Others did not perceive any changes in communication about PMI in the home due to it being challenging to maintain the communication skills learnt during intervention sessions	“to be calm... to actually listen, I know I listen to what the kids say... but I’d learned to actually listen properly to what they were saying not just the bits and pieces I wanted to hear... I think it’s really helped me.” (Adult; ID:79) "Simply the, uh, distance to the topic was kind of gone afterwards and that helps of course, yes, I have to admit that helped me an incredible amount." (Parent of family 8, ID-n: 16) “How much should we talk to him about this at all? It feels difficult […] if we are going to talk more about it then we need some more help to know how to raise the issue.” (Henny, ID-n: 2)
3. Normalisation and like-mindedness
3.1 Reducing shame and guilt, feeling normal	For those that took part in group interventions, parents reported feeling less alone in their experiences. These social connections, but also the psychoeducation provided, helped families feel less guilt and shame around their mental illness	“I felt quite lucky and I’d sometimes walk into the group feeling really down and really sad and really alone and really isolated and then I’d look at the group and think, hang on, yes, I’m like this but my life is really not that bad... it’s good to know that people are in the same boat as you... It’s made me feel less guilty.” (parent, ID-n: 10) “It does help because…I feel a bit normal, sometimes I do not feel good, I’m strange, I’m different it makes me feel normal and it makes [my child] more relaxed…..it makes us more relaxed about me, because when as well when [my child] just started to realize that I have some problems they were very scared because it is scary if you don’t know what you deal with and somehow they put it in the normal perspective, normal like sort of it’s okay.” (Parent current attendee, ID-n 59)
Topic 2: Intervention acceptability and families’ experiences of taking part
4. Initial engagement	Families were reluctant to participate for a variety of reasons, including • Feeling guilt and shame • A lack of understanding of the intervention • Being nervous of the unknown, or the group • Reluctancy to engage other family members (e.g., worry about the impact of talking about PMI with children)	“I felt shy, I wondered what it was going to do, what it was about. Now I know. It is about having fun and mental illness so when mum or dad get ill, you can help them.” (Young attendee, ID-n 214)
5. Role of facilitators
5.1 Engagement	Facilitators were perceived to have an important role in engaging families in the interventions. This included meeting people before the interventions began and creating a safe and non-judgemental space. Facilitators made the confidentiality and privacy of the sessions clear, as well as being welcoming and friendly to create a comfortable atmosphere for families. One study raised that having consistent facilitators (i.e. low staff turnover) was also important	Families required extensive preparatory input from clinicians to allay their fears to persuade them to engage with FT. (ID-n 206) The parents experienced the intervention meetings as a safe and non-judgemental context for them and their family. These feelings helped them to speak openly about things that could be painful. (ID 2) I think [Young SMILES facilitator] was lovely. I think her approach... her happy, bubbly personality, I think really took off in the group. She was very easy to talk to and any issues I’ve had outside the group, she’s been fantastic and supportive. I think that’s really good. (ID 10)
5.2 Skills	Skills of the facilitator were also deemed important and related to managing groups, providing child-centred care (for children of different ages), having appropriate knowledge and expertise, managing different perspectives, and engaging families	The majority of PMIs and partners indicated that it was the skill of FT clinicians that mediated the benefits for families. (ID-n: 206)
6. Content
6.1 Focus of topics	Most families were happy with the topics being discussed (see benefits). For some, the focus was too narrow or slightly misplaced (e.g., too much on child or parent, or not enough on problems of other family members). In some intervention, intervention-specific topics were deemed helpful by families, such as the focus on culture and immigration in Family Strength (ID 91). Other elements were perceived with mixed feelings, such as the joint parent–child exposure in the Enhanced transdiagnostic CBT (ID 213)	“It was directed towards me as I’m the one who is ill. Sometimes I felt that everything was my fault because I’m ill, as if ‘you’re ill and therefore you’re the problem and it’s you we have to fix.” (Parent ID-n:2) Parents endorsed both positive and negative experienced or anticipated emotions in response to the observational exposures, suggesting a complex or mixed feeling state. (ID-n: 213)
6.2 Talking about PMI	Many interventions facilitated in-session talk about PMI. Opening up and discussing things in sessions could be emotionally challenging for some, due to fear of disclosure or a lack of confidentiality. There were fears about how others in a group setting may respond	It became apparent that, for some CYP, a major barrier to talking was the expectation that their thoughts and feelings would be shared with their parents. (ID-n: 10) The findings suggest that FT was challenging for many families despite the non-judgemental support provided by FT clinicians. Several parents/partners reported difficulties in speaking openly in sessions and/or listening to the experiences of family members. (ID-n: 206)
7. Intervention format, structure, and logistics
7.1 Length and intensity	A recurring theme was the need for more or longer support. Families wanted more time to discuss the topics or do the exercises of the interventions. This was sometimes because they felt the intervention was rushed or crammed, or because it took time to feel enough trust to fully participate. Some families wanted to continue their meetings with the other families to continue to build on the social connections made. For some families, the interventions were too intensive, for example because the assessment was invasive, homework was too much, or because it was time-consuming	“I think more sessions with the family... and more time with the children would have really helped. The three of them went in one by one for 20 min. So it might have been a little bit rushed for them, they might not have had enough time.” (PMI 16. ID-n: 206) “When we finished the programme I didn’t have no-one else to talk to and I wanted to see [the workers] to speak to them a bit more... I felt quite sad because you had just go to know all the workers there and all the kids there but then you wouldn’t get to see them no more.” (Child, ID-n: 79) The most commonly named disadvantage to participating in the intervention was how tiring and time-consuming it was (N = 17) due to weekly sessions and homework assignments. (ID-n:16)
7.2 Group approach	Both adults and children talked about the benefits of connecting with other families in similar circumstances and share experiences Being together provided a safe space for some to discuss things they might not discuss with anyone else. Whereas for others, the group felt unsafe, they were nervous to share information, or they had unpleasant experiences with other group members Individual characteristics also impacted the acceptability of group approach, including having a different language, children with a disability, and the age range of children. Wide age ranges made it hard to accommodate the needs of all children. Some older children felt as an outsider or did not enjoy it, because they did not have anyone of their age	“I felt quite lucky and I’d sometimes walk into the group feeling really down and really sad and really alone and really isolated and then I’d look at the group and think, hang on, yes, I’m like this but my life is really not that bad... it’s good to know that people are in the same boat as you... It’s made me feel less guilty.” (parent, ID-n: 10) “The open group talks allowed us, including myself, to really open up and speak about things I couldn’t imagine talking about with any of my friends.” (Child, ID-n: 79) Disappointment by lack of meaningful conversations about personal experiences left some parents feeling isolated, like ‘a stranger at a bus stop’ (N29P01A1), whereas others felt frustration with their experience of being in a group with parents who did not contribute. (ID-n: 10) “Well, basically, like I just asked them how they figure out their problems and they tell me and I just tell them how I do it.” (ID-n: 10)
7.3 Interactive activities	Interactive and dynamic activities were perceived as helpful and enjoyable by families, for example drama and role-play. Having fun and playing (with friends) was deemed important, especially for children. It provided a welcome break of the hardship at home	“Home was sad, Kidstime was fun. That’s what I looked forward to. I looked forward to having fun, you know being a child. But at home you have to be an adult, look after yourself, look after mum, look after the house, give her medication; at Kidstime you’re having fun. You’re being looked after and you’re not looking after others. …there are people there who are paying attention to you and you can go and speak to because you probably can’t speak to your mum because you know she’s not well she probably won’t understand. But Kidstime was time for the kids; I think that’s why it’s called Kidstime.” (Young person past attendee, ID-n: 59)
7.4 Manual	There were contrasting views about manuals in the interventions. In Family Talk (ID2), the manual and the structure that was provided was seen as a positive. Whereas families and facilitators in Young Smiles (ID 10) reflected on the need for the sessions to have flexibility to meet the individual needs of families	Some emphasised that they appreciated the structure of the intervention and that the care providers followed a manual. One parent expressed that the structure made her feel safe and secure, another parent expressed that it could have been ‘messy’ without a manual. (ID-n: 2) Facilitators’ abilities and efforts in adapting to individual circumstances were key to the acceptability of the intervention and continued participation. Providing individual support when required was valued. (ID-n:10)
7.5 Setting and environment	The location and time of the interventions impacted acceptability. Participation was sometimes difficult due to accessibility issues and facilitators had to support organising transport	Engagement could also be compromised by issues in terms of organisation of transport to the workshops. (ID-n: 59)
7.6 Whole-family component	The family component of interventions allowed for many of the benefits listed above (having fun together, shared understanding, listening to each other). Some families mentioned that they would have liked additional family members or even peers to have joined in the intervention. Some families said they would have wanted more family time during sessions. In Young Smiles, lack of parental engagement was observed to relate to worse outcomes. Nevertheless, some families described that separate sessions could also be beneficial, providing a space of respite for the children	“Some parents highlighted that they found it particularly valuable to listen to children speak about their experiences and feelings, with some of the facilitators emphasising the importance of giving children a voice.” (ID-n: 79) “It was kind of good because mum wouldn’t be there and she wouldn’t be seeing the stuff that we said. Not saying that in a bad way but like, she would just go ‘don’t say that’.” (ID 10) A small number of cases where participants wished that other members of their family, such as younger children or misusing parents, could attend. (ID-n: 79) “Because you get to spend time with them and I don’t really do that.” (ID-n: 10)