Hindawi Publishing Corporation
Volume 2013, Article ID 897084, 7 pages
Involving the Family in the Care and Treatment of Women with
Postpartum Psychosis: Swedish Psychiatrists’ Experiences
I. Engqvist1,2and K. Nilsson3
1School of Life Science, University of Sk¨ ovde, P.O. Box 408, 541 28 Sk¨ ovde, Sweden
2Department of Psychiatry, Skaraborg Hospitals, 521 85 Falk¨ oping, Sweden
3Institute of Health and Caring Sciences, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
Correspondence should be addressed to I. Engqvist; firstname.lastname@example.org
Received 17 November 2012; Revised 5 January 2013; Accepted 11 January 2013
Academic Editor: Yvonne Forsell
Copyright © 2013 I. Engqvist and K. Nilsson. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
The aim of the study was to describe Swedish psychiatrists’ experiences of involving the family in the treatment of women with
psychiatrists from the south of Sweden. Data were analysed using qualitative content analysis. Four categories were found: the
family as a resource, the family as coworkers, preparing the family for the future, and the family as a burden. The result showed that
the psychiatrists considered the family to be a resource to which they devoted a great deal of care and effort. It was particularly
important to involve the partner, informing about the course of the illness and the steps that need to be taken in the event of a
relapse and reducing any guilt feelings. The psychiatrists instilled confidence and hope for a future of health and further child
bearing. The family members’ limited understanding of the treatment may impede the involvement of the family. Conclusion of
the study was that the goal for family involvement was to facilitate the women’s care and treatment. Further studies are needed to
provide suggestions on how to develop family involvement in the care of women suffering from postpartum psychosis.
Suffering from postpartum psychosis (PPP) calls for all
possible forms of support as this is a rare illness [1, 2].
Involving families in patient care and treatment has also
been found to be important in the recovery of people with
psychiatric disorders , not least PPP . The involvement
or participation of relatives in supporting the patient during
the hospital stay is laid down in Swedish law . According
to law, involuntary psychiatric treatment should be provided
as far as possible with the cooperation of the patient and his
or her relatives . The Swedish National Board of Health
and Welfare  describes this participation as the patient’s
treatment options, and the opportunity for a second opinion.
The regulations of the National Board of Health and Welfare
 state that the quality system must ensure that patients
and their relatives are informed and are involved in the
care process. In this study, the focus is on the experience
of Swedish psychiatrists of involving family members in the
care and treatment of women with PPP. A family member is
defined as a close relative or next of kin.
Family involvement has been investigated in relation to
mental illness in general. Close family members maintain
frequent contact with a person suffering from severe mental
illness, such as a psychotic disorder, while the person’s social
network, such as friendships, often breaks down . From
the individual’sperspective, the family’ssocial and emotional
support has been found to be of considerable value and an
important factor in the recovery process . In a review by
Saunders , it was shown that family members could be an
the families in planning and care has a strong influence on
2 Psychiatry Journal
brief family involvement will improve health and recovery,
reduce the risk of a relapse, and increase family wellbeing
As mentioned, the focus of this study is on psychiatrists’
PPP. Even if this illness is quite rare—one-to-two women per
1,000 births develop PPP —it is important to find how to
severe. The consequences could be traumatic and sometimes
result in suicide and infanticide . The majority of cases
occur within the first few weeks  after childbirth, with a
rapid onset of delusions, hallucinations, and impaired reality
[16, 17]. The prognosis for PPP is favourable. With treatment,
the woman usually recovers within a few weeks, perhaps up
to a year .
In Sweden, psychiatrists care for women with PPP in
several stages in the care process. Women with PPP typically
receive inpatient treatment at a hospital for a short period,
followed by outpatient treatment [18–20]. In Sweden, the
mother and baby are usually discharged from the postnatal
unit 1–4 days postpartum. The majority of the stricken
women are discovered before discharge, and the remainders
Sweden, there are no specialist mother and baby units, and it
for the baby to be cared for by the partner/husband or other
of this study. Both inpatient and outpatient care is provided
in collaboration with several other healthcare professionals,
including nurses, psychologists, and social workers .
It has been found in some studies [22, 23] that the
majority of family members have insufficient opportunity to
be involved in the patient’s treatment. In a study from USA
 covering 453 clinicians, it was found that the clinicians’
attitude was poor with regard to participation by relatives
in the care process. There were many barriers, including
the attitude that relatives lacked interest, relatives were also
mentally ill, and relatives had unrealistic expectations about
the patient’s progress.
Contrary to these studies, Lakeman  found that the
majority of family members were satisfied with their partici-
pation in the treatment. No studies have been found describe
ilies of women with PPP during the period of care and treat-
ment. The aim of this study therefore is to describe Swedish
psychiatrists’ experience of involving family members when
caring for women suffering from postpartum psychosis.
A secondary analysis was conducted of the data collected
from an earlier study that described the treatment approach
employed by Swedish psychiatrists caring for women with
PPP . This study revealed that the psychiatrists focused
on protecting women with PPP from suicide and infanticide.
Treatment focused on maintaining patient safety along with
prompt medical treatment. The reason for this secondary
analysis was that the psychiatrists’ statements gave the
impression that questions concerning cooperation with the
patient’s family could be answered. A qualitative design was
chosen for the project in order to shed some light on the care
of women with PPP [26–28].
The study was conducted in the south of Sweden. The
ticipation was that the psychiatrists should have at least five
years’ professional experience to ensure that they had treated
women with PPP. We commenced the study by contacting a
psychiatrist and asking for help to find doctors who might be
the names of other doctors, all of whom were contacted.
We contacted 12 psychiatrists in all and nine agreed to
participate. Three of them subsequently declined because of
a heavy workload. All the psychiatrists were contacted, and
interviews were conducted by the first author (IE).
Nine leading psychiatrists, five male and four female, all in
senior positions, participated in the study. Training to be
a medical doctor in Sweden takes seven years and three
months, and to be a trained specialist, that is, a psychiatrist,
requires five years of further training. All psychiatrists in the
study were trained in Sweden and were active in different
areas of the country. Three of them had a Ph.D., which is
an advantage when holding a top management or research
position. In Sweden, about 15% of doctors have Ph.Ds .
Consequently, the participants had received more scientific
ran a psychiatric research programme, and one had previ-
ously conducted research on women diagnosed with PPP.
5. Data Collection
Data were collected from October 2007 to February 2008
using semistructured qualitative research interviews with
psychiatrists. They were contacted by telephone, whereupon
the study was described and participation was requested.
An introductory letter, describing the purpose of the study,
was sent to the participants. Before the interviews were
conducted, the participants were once again told about the
purpose of the study, and written, informed consent was
obtained. The interview guide was structured according to
the following themes: how to involve the husband and the
and cons of involving the husband and the family. These
themes were introduced by asking the psychiatrists to give
their views on each of the themes. Short and direct questions
were used to probe for accuracy, clarity, and further details
when necessary. Analysis of the data did not begin until all
the interviews had been conducted. Eight psychiatrists were
The interviews lasted 35–70 minutes.
6. Data Analysis
The data were analysed using qualitative content analysis;
both the manifest content of a text (i.e., what the text says)
and the latent content (i.e., what the text talks about) .
content analysis, each audiotaped interview was transcribed
verbatim. The text was then read several times to obtain
an overall impression. In the next step in the analysis, the
units of meaning (manifest content) were extracted from
the text and with the study objective constantly in mind.
These were then decontextualised and shortened. Finally, the
codes were comparedconsistently to identify similaritiesand
differences (latent level). This comparison process resulted
in putting the codes with associated units of meaning and
data, whereupon the final four themes were formulated.
The authors contributed in the data analysis with their
specific perspective. The first author (IE) is a psychiatric
nurse. This may be seen as a limitation and preunderstand-
ings may be difficult to eliminate. Therefore, the first author
consistently tried to be aware of the preconceptions. The
therefore provided objectivity in the analytic process.
7. Ethical Considerations
Under Swedish law , approval from an ethics committee
was not required at the time of the interviews. However,
under this act and the Helsinki Declaration, participants are
required to give their informed consent. Consequently, ethi-
cil , were followed and the participants were informed
about the study objectives and the data collection method.
They were informed that participation is voluntary, that the
information would be treated in confidence, and that they
The results describe the psychiatrists’ experience of involving
the family when caring for and treating women with PPP.
For the psychiatrists, the predominant goal for family
9. The Family as a Resource
All the doctors interviewed stressed the importance of the
family as a resource that should be utilised and benefitted
from during the woman’s hospitalisation. To this end, they
used a little extra persuasion to get the family involved.
They stated that involving the partner and close relatives is
vital in facilitating the woman’s care and her recovery, and
they placed considerable emphasis on family participation. If
the family participates and is familiar with the care during
the woman’s hospitalisation, the follow-up care will also be
strengthened due to their knowledge of the illness and what
to expect during the recovery phase.
When the woman was admitted to a psychiatric depart-
ment, the task of informing and involving the family began.
The person addressed in particular was the husband/partner,
who received special attention from the clinicians. The
doctors said that they explained to the husband/partner that
things, such as he is not the child’s father. They explained
this by saying “She means nothing by this; this is simply
the brain acting freely” [psychiatrist 4]. The doctors stated
that early efforts to involve the family during hospitalisation
will provide more confidence and strengthen the family’s
sense of concern and their appreciation for the ongoing care.
It may also have implications for the care provided after
In the way we work here, we consider family
deal of emphasis on this [psychiatrist 6].
One of the doctors described his way of involving the
family and the husband/partner in this way:
Something I discovered early on, and which is
to the husband. By talking to him and by giving
him his own point of contact...//... I make sure
he has his own time with me, so that I can explain
so quickly and frequently they do not understand
anything [psychiatrist 5].
Considerable effort was made to educate and inform the
family, for whom the illness was incomprehensible. They had
perhaps never heard of the illness the woman was suffering
from, and it was the responsibility of the doctors to inform
and help the family to understand the true nature of the
illness. They explained what a psychosis is, that is, that the
brain leaves normal reality behind and sees, hears, and says
things that are not normal reality. The illness often produces
a sense of guilt among those who are ill and among their
relatives. They blame themselves for the woman’s illness. This
applied mostly to the husband. The doctors felt it was vital to
the illness and its symptoms. At an early phase in the illness,
the doctors pointed out the good prognosis. Information of
this nature reduced the family’s feeling of blame and guilt:
I like to control the flow of information. Many of
them will go home and straight on to the Internet.
They go home and Google and end up on less
serious websites that are there only to confuse
the patients. I want to try to control this flow of
will allow them to read and learn. I sit down with
them and give them an understanding of what
she says right now, such as you are not the father
of the child and a lot of other stuff. She is just sick.
4 Psychiatry Journal
is involved. I describe what a psychosis is and
try to reduce the guilt that usually goes with it
10. The Family as Comorkers
When the doctor and the nursing staff in the team caring for
the woman also bothered about and cared for the husband
and other family members, the family in turn felt accepted
and became partners in the woman’s care. They felt appre-
ciated and useful, which made it easier for them to provide
support and assistance in the care process. The woman
received support and the family could remain with her on
the ward and when on leave from hospital. Being involved in
the care, the family made sure she took her medication and
they supported her in her own daily care as well as caring for
her baby. Being involved created security. When the family
it could help to shorten the hospital stay. If a therapeutic
relationship has been established, it will be easier for the
family to return to the hospital in the event of a relapse:
Yes, she received exemplary support from the
husband and her parents. She received very good
support [psychiatrist 1].
It’s important that you get them on board. Then
they can be a valuable resource, even later on
Working with the family, cooperation with the sick woman
usually improved. The family became a link to the woman.
Most of the time, cooperation with the woman was difficult,
with problems obtaining her consent regarding care and the
different care decisions. If the family agreed, they in turn
helped the woman to become more willing to participate in
her care and approved healthcare decisions.
from early signs of the illness and try to establish
the best possible relationship with the patient. I
think most of the time this is not too difficult.
They usually like it when I’m involved. If I’m there
them later on as an outpatient [psychiatrist 2].
Good cooperation with the husband and the family was
built up by the doctor providing information and knowledge
and establishing a good reputation. In turn, the family
participated in the care and shared their knowledge about
the sick woman’s background. It became two-way communi-
cation. An exchange of experience would benefit the woman
throughout the time she was ill, both in hospital and during
her continued treatment.
The father was really good and realised that she
was ill. We worked well together and she was
admitted to hospital for a week, maybe ten days
When cooperation worked well, the husband felt it was
positive to be involved in the various care visits during the
time in hospital and later.
In cases such as this, the husband needs to
participate. When visiting and so on. This is true
for visits by the doctor, the nurse, counsellor and
so on [psychiatrist 7].
If the family did not understand or accept care decisions,
it was more difficult to implement care and treatment. If
the woman was subject to a compulsory care order, it was
the doctor’s decisions that counted although the doctors
always tried to obtain the woman’s and her relatives’ consent
even when she was under compulsory care. The optimal
situation was if the woman and her family agreed to or at
least understood that the decisions were necessary as a basis
for the care that was being provided. If it became necessary
to use coercive measures, such as medication with the aid
of restraint or force, it was vital that the husband/family
understood the importance of this type of care and that they
were prepared for it:
We always put her on compulsory care. She
must always be under such care. It is by far the
best for everyone. This is something that is very
deep-seated ... That’s my personal opinion and
11. Preparing the Family for the Future
approach [psychiatrist 5].
Instilling hope, joy, and encouragement for the future was a
fundamental task of the doctor when providing information
to the husband/partner—to instil patience and tolerance
regarding the present situation and to make him believe
in future together. The doctor needed to make the partner
realise that despite the ongoing illness the woman would
eventually recover and in the future be well enough to take
care of her child and her family. There was a need to remind
its most severe, the doctors felt that this was necessary. Once
the illness had been treated and the woman recovered, there
would be an opportunity to have more children:
Provide him [the husband] with information and
encouragement. Get him on board and secure his
consent to the treatment I know she needs. Instil
faith and hope for their future [psychiatrist 5].
During the hospital stay, the doctors began providing
information about how spouses/couples should approach a
possible future pregnancy. They argue that it was necessary
for different care professionals to work together although it
was equally necessary for cooperation with the husband and
family. They talked about the importance of the woman and
her husband coming along for a visit prior to pregnancy
to discuss support for the woman and how to build up a
network of specialised prenatal care, including a psychiatrist,
to support her. The husband/partner and other relatives
around her needed to be involved in this networking:
a functioning network of contacts: prenatal care,
us and the family [psychiatrist 9].
12. The Family as a Burden
The doctor did not always succeed in creating a useful and
trusting relationship or affiliation with the relatives and the
patient. Sometimes the families opposed the care that had
been decided and failed to understand that the care was
necessary for the woman to recover. At times, it was not easy
to work with the husband and family. Sometimes it made the
family determined to thwart the treatment. They complained
and occasionally they even took the woman home to treat
her there. Unless the women were under compulsory care,
this could not be refused. Once in a while, the family acted
wrongly and sometimes they did not understand any better.
At times, the family was concerned for their loved one, and
it could lead to incorrect behaviour. The family might make
every effort to spoil the treatment and care.
that!” Six hours later, they were back. They threw
her into the ward and said: “Take care of her!”
In the past, psychiatric care has been bad at including the
family in the care process. Relatives were often left out and
one. The psychiatrists stated that they had tried to alter this
the ongoing care:
The family is very important and those of us
working in psychiatric care are incredibly poor at
including them. We are very slack when it comes
to making contact with relatives [psychiatrist 6].
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’
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
importance of the family and noted that the family increased
their understanding of inpatient care by providing informa-
tion. This was also noted in the present study. Sj¨ oblom et al.
 is a study of nurses, but it is reasonable to assume that
the same applies to doctors working in the same context.
with PPP is crucial to the recovery process. Families need
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 [32–34].
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? Stjernsw¨ ard
and¨Ostman  investigated the experiences of families
living close to an individual with depression. They reported
that families felt that they were not always considered or
and McAndrew , 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
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 . 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. , fathers who cared for their infants
considered the increased time with the child to be very
appeared in the spectrum, the father later experienced a
stronger and more lasting bond with the child. As reported
by Erlandsson et al. , 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
All doctors are accustomed to working with husbands/
partners and close relatives of the women. Since relative
participation is enshrined in Swedish law , 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  in a
found that the family was not always a priority in this caring
context. Is there a difference between doctors and nurses?
made by the doctors and are not what they might do or think
6 Psychiatry Journal
in practice. In an interview, people say what they want to
say at that moment . 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?
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,
the doctor can have a trusting relationship with the husband,
family or the husband of cooperation and no approval of the
woman’s care, the decision how to act for the doctor depends
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. , it
is reported that the majority of relatives interviewed in the
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  of strategies employed
by nurses in connection with women with PPP, which also
identified the importance of instilling hope, encouragement
(푛 = 9) although the interview data are rich, describing rele-
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.
vant experiences and providing a deep understanding of the
The conclusion of the study is that the goal for family
involvement is to facilitate the women’s care and treatment.
The psychiatrists stated that they put a great deal of effort
into involving the family in the woman’s care and treatment
and that they make a particular point of trying to include
the husband in the care process with the aim of securing
his approval and understanding. They tried to inform the
family about the course of the illness and what steps to
take if there is a relapse. They tried to instil hope and
confidence in a prosperous future and further child bearing.
The family members’ limited understanding of the treatment
may impede the involvement of the family. Further studies
are needed to provide suggestions on how to develop family
involvement in the care and treatment of women suffering
from postpartum psychosis.
Ethical approval for this kind of research is not required
under Swedish law .
Conflict of Interests
The paper has been submitted exclusively to Psychiatry Jour-
nal and there is no conflict of interests.
I. Engqvist made study design, data collection, analysis, and
analysis and paper preparation.
The study was supported by the Department of Psychiatry at
Skaraborg Hospital, the Research Fund at Skaraborg Hospi-
tals, the King Oscar II and Queen Sophia Golden Wedding
Anniversary Foundation, and the Skaraborg Institute for
Research and Development.
 R. E. Kendell, J. C. Chalmers, and C. Platz, “Epidemiology of
puerperal psychoses,” British Journal of Psychiatry, vol. 150, pp.
diagnoses and relative risk of admission after parturition,”
British Journal of Psychiatry, vol. 172, pp. 521–526, 1998.
 A. M. Heru, “Family psychiatry: from research to practice,”
American Journal of Psychiatry, vol. 163, no. 6, pp. 962–968,
 B. Posmontier, “The role of midwives in facilitating recovery
in postpartum psychosis,” Journal of Midwifery and Women’s
Health, vol. 55, no. 5, pp. 430–437, 2010.
 “The health and medical service act (1982:763), Ministry of
Health and Social Affairs, Stockholm, Sweden”.
2008:415). Ministry of Health and Social Affairs, Stockholm,
 “The National Board of Health (2003-103-5). Patientens r¨ att
till information, delaktighet och medinflytande. (In Swedish.
The patient’s right to information, participation and empower-
f¨ oreskrifter om ledningssystem f¨ or kvalitet och patients¨ akerhet
i h¨ also- och sjukv˚ arden. (In Swedish. The National Board of
Psychiatry Journal7 Download full-text
Health regulations on quality management and patient safety
in health care”.
 E. Edwards and S. Timmons, “A qualitative study of stigma
among women suffering postnatal illness,” Journal of Mental
Health, vol. 14, no. 5, pp. 471–481, 2005.
 M.Ewertsson,K.L¨ utz´ en,E.Svensson,andB.Andershed,“Fam-
ily members’ involvement in psychiatric care: experiences of
Journal of Psychiatric and Mental Health Nursing, vol. 17, no. 5,
pp. 422–432, 2010.
 J. C. Saunders, “Families living with severe mental illness: a
literature review,” Issues in Mental Health Nursing, vol. 24, no.
2, pp. 175–198, 2003.
 E. Benzein, P. Johansson, F. K. ˚ Arestedt, and B. I. Saveman,
“Nurses’ attitudes about the importance of families in nursing
14, no. 2, pp. 162–180, 2008.
 I. Brockington, “Diagnosis and management of postpartum
disorders,” World Psychiatry, vol. 3, no. 2, pp. 89–95, 2004.
 G. G. Knops, “Postpartum mood disorders: a startling contrast
 American Psychological Association, Diagnostic and Statistical
Manual of Mental Disorders, Washington, DC, USA, 4th edi-
 J. Heron, M. McGuinness, E. R. Blackmore, N. Craddock, and
I. Jones, “Early postpartum symptoms in puerperal psychosis,”
An International Journal of Obstetrics and Gynaecology, vol. 115,
no. 3, pp. 348–353, 2008.
 J. Heron, E. Robertson Blackmore, M. McGuinness, N. Crad-
dock, and I. Jones, “No ’latent period’ in the onset of bipolar
affective puerperal psychosis,” Archives of Women’s Mental
Health, vol. 10, no. 2, pp. 79–81, 2007.
 I.Engqvist,A.˚ Ahlin,G.Ferszt,andK.Nilsson,“Comprehensive
treatment of women with postpartum psychosis across health
care systems from swedish psychiatrists’ perspectives,” Qualita-
tive Report, vol. 16, no. 1, pp. 66–83, 2011.
 H. Hagberg, K. Marsal, and M. Westgren, Obstetrik, Elanders
Hungary Kft, Studentlitteratur, Hungary, 2008.
 H. Silfverhielm and E. Kamis-Gould, “The Swedish mental
health system: past, present, and future,” International Journal
of Law and Psychiatry, vol. 23, no. 3-4, pp. 293–307, 2000.
 I. Engqvist, A. Ahlin, G. Ferszt, and K. Nilsson, “Nurses—
psychiatrists’ main collaborators when treating women with
Nursing, vol. 17, no. 6, pp. 494–502, 2010.
 M.¨Ostman and L. Hansson, “Need for support and participa-
tion in treatment differences among subgroups of relatives to
European Psychiatry, vol. 14, no. 7, pp. 379–385, 1999.
 M. Ostman, L. Hansson, and K. Andersson, “Family burden,
of the situation of relatives to compulsorily and voluntarily
admitted patients,” International Journal of Social Psychiatry,
vol. 46, no. 3, pp. 191–200, 2000.
 H. W. Kim and M. P. Salyers, “Attitudes and perceived barriers
to working with families of persons with severe mental illness:
mental health professionals’ perspectives,” Community Mental
Health Journal, vol. 44, no. 5, pp. 337–345, 2008.
 R. Lakeman, “Practice standards to improve the quality of
family and carer participation in adult mental health care:
an overview and evaluation,” International Journal of Mental
Health Nursing, vol. 17, no. 1, pp. 44–56, 2008.
Publications, London, UK, 1992.
of Qualitative Research, N. Denzin and Y. Lincoln, Eds., Sage
Publications, London, UK, 1994.
 D. F. Polit and C. T. Beck, Nursing Research. Generating and
Assessing Evidence For Nursing Practice, Lippincott Williams &
Wilkins, Philadelphia, Pa, USA, 8th edition, 2006.
the amount of PhDs,” Lakartidningen, vol. 28, pp. 2123–2125,
in nursing research: concepts, procedures and measures to
achieve trustworthiness,” Nurse Education Today, vol. 24, no. 2,
pp. 105–112, 2004.
 The act concerning the ethical review of research concern-
ing humans (2003:460). Ministry of Education and Research,
 L.-M. Sj¨ oblom, A. Pejlert, and K. Asplund, “Nurses’ view of the
family in psychiatric care,” Journal of Clinical Nursing, vol. 14,
no. 5, pp. 562–569, 2005.
 M. Blomqvist and K. Ziegert, “Family in the waiting room: a
Swedish study of nurses’ conceptions of family participation
in acute psychiatric inpatient settings,” International Journal of
Mental Health Nursing, vol. 20, no. 3, pp. 185–194, 2011.
 A. Schr¨ oder, B. Wilde Larsson, and G. Ahlstr¨ om, “Next of kin’s
conceptions of the quality of care in the psychiatric setting:
a phenomenographic study,” International Journal of Mental
Health Nursing, vol. 16, no. 5, pp. 307–317, 2007.
 S. Stjernsw¨ ard and M. ¨Ostman, “Whose life am I living?
Relatives living in the shadow of depression,” International
Journal of Social Psychiatry, vol. 54, no. 4, pp. 358–369, 2008.
 C. Wilkinson and S. McAndrew, “‘I’m not an outsider, I’m his
mother!’ a phenomenological enquiry into carer experiences of
exclusion fromacute psychiatric settings,”International Journal
of Mental Health Nursing, vol. 17, no. 6, pp. 392–401, 2008.
experiences of getting to know their baby while acting as
primary caregivers immediately following birth,” The Journal of
Perinatal Education, vol. 17, no. 2, pp. 28–36, 2008.
 J. J. Chang, C. T. Halpern, and J. S. Kaufman, “Maternal
depressive symptoms, father’s involvement, and the trajectories
Pediatrics and Adolescent Medicine, vol. 161, no. 7, pp. 697–703,
 M. Edhborg, W. Lundh, L. Seimyr, and A. M. Widstr¨ om, “The
parent-child relationship in the context of maternal depressive
 D. Silverman, Interpreting Qualitative Data Method For
Analysing Talk, Text and Interaction, Sage Publications,
London, UK, 2001.
 I. Engqvist, A. Nilsson, K. Nilsson, and B. Sj¨ ostr¨ om, “Strategies
in caring for women with postpartum psychosis—an interview
study with psychiatric nurses,” Journal of Clinical Nursing, vol.
16, no. 7, pp. 1333–1342, 2007.