The family plays an important role in the care of patients in all areas of healthcare, and this is true in psychiatric care. The aim of this study is to describe Swedish psychiatrists' experience of involving family members in the care of women with postpartum psychosis. Four categories were found: the family as a resource; the family as co-workers; preparing the family for the future; the family as a burden. These categories are discussed below.
In this study, all the psychiatrists interviewed were of the opinion that it is essential to involve the family in the care of a woman with PPP. Involving the family makes it possible to use their knowledge of the woman to facilitate her care and treatment. The husband/partner is particularly important and a great deal of effort is made to involve him and make him a partner in the ongoing treatment. This is in line with the findings of Sjöblom et al. [32
] in a study of nurses working in an acute psychiatric setting. The study verified the importance of the family and noted that the family increased their understanding of inpatient care by providing information. This was also noted in the present study. Sjöblom et al. [32
] is a study of nurses, but it is reasonable to assume that the same applies to doctors working in the same context.
Providing information to or educating families of women with PPP is crucial to the recovery process. Families need educating in order to understand the course of the illness and to acquire coping and problem-solving skills. It also reduces the feeling of guilt that usually accompanies this illness, both for the women and their relatives. This is an urgent task for the doctors and is in accordance with earlier research, which suggested that information given and received is of considerable value in psychiatric care and can reduce the families' feelings of shame and guilt [32
It is also noted in the present study that it is not always the case that the relatives of the patients have been seen and are included in psychiatric care. What are the implications of such attitudes for families in clinical practice? Stjernswärd and Östman [35
] investigated the experiences of families living close to an individual with depression. They reported that families felt that they were not always considered or treated well by healthcare personnel. According to Wilkinson and McAndrew [36
], families frequently felt excluded from acute psychiatric settings and sought a greater degree of participation in the care. In the present study, this was not noted among the doctors. They attempted to change this way of acting, aiming to establish a good working relationship with families and trying to increase the family's involvement in the ongoing care and treatment.
In Sweden, it is normal for the mother and child to be separated when the mother is diagnosed with PPP. The illness is severe and joint care may be impossible for the first few days. It is generally the father who becomes the primary caregiver at home [18
]. The bonding will have to wait for the mother's part, even if they may be able to meet again after a few days. The connection to the father becomes stronger and he may replace the absent mother entirely. According to Erlandsson et al. [37
], fathers who cared for their infants considered the increased time with the child to be very valuable. Although longing and togetherness with the woman appeared in the spectrum, the father later experienced a stronger and more lasting bond with the child. As reported by Erlandsson et al. [37
], the father-child relationship is deepened when the father assumes more responsibility while getting to know his child. If the mother is incapable of caring for the baby, scientific studies show the importance of the father taking over in order to interact and care for the child [38
All doctors are accustomed to working with husbands/partners and close relatives of the women. Since relative participation is enshrined in Swedish law [5
], the doctors boost their efforts to involve families. The question is what do they really think? Do they find that using family members benefits care or do they emphasise family work so much because it is stipulated in law and they are compelled to use family members and involve and inform them? This is difficult to know and the interviews provide no real information. According to Blomqvist and Ziegert [33
] in a study of nurses working in an acute psychiatric setting, it was found that the family was not always a priority in this caring context. Is there a difference between doctors and nurses?
It is important to remember that the results are statements made by the doctors and are not what they might do or think in practice. In an interview, people say what they want to say at that moment [40
]. The doctors clearly understand that the families can provide information and knowledge about the woman that they would not receive otherwise. It also came out in the interviews that relatives can be a nuisance, they do not always follow instructions, and they could have a detrimental effect on the care process. How do the doctors treat a husband who refuses to accept the treatment and does not grant his permission for the care that is being provided? According to this study, the doctors try hard to get on friendly terms with the husband and contact him at an early stage, inform him about the woman and her illness, and establish a good relationship with him. This is similar to a friendship, with the two of them pulling together and moving forward. If the doctor can have a trusting relationship with the husband, the husband could be of use during the hospitalisation period and later on in the follow-up care. If there is no desire from the family or the husband of cooperation and no approval of the woman's care, the decision how to act for the doctor depends on whether the woman is on compulsory care or on voluntary care. When on compulsory care the doctor's decision applies. If the woman is on voluntary care, she can leave the hospital and return home. If the illness worsens, she will return to the hospital on compulsory treatment.
The doctors also recognise the need to provide hope and encouragement for the future by reminding the couple that the illness does have an end and a good prognosis. They also start preparing the couple early on for the next pregnancy by providing information. In a study by Ewertsson et al. [10
], it is reported that the majority of relatives interviewed in the study stated that they had experienced a negative approach by the healthcare professionals, revealing a lack of confirmation and cooperation. This is not borne out in this present study. The doctors' statements, however, are in line with findings from an earlier interview study [41
] of strategies employed by nurses in connection with women with PPP, which also identified the importance of instilling hope, encouragement and confidence.
In this study, the limitation could be the small sample size (n = 9) although the interview data are rich, describing relevant experiences and providing a deep understanding of the phenomenon in question. The open-ended questions gave the psychiatrists an opportunity to reflect on their experiences and to speak freely. In addition, the interviewer's knowledge and experience in the field facilitated the interviews. The richness of the data came from openness and a mutual understanding of the research field.