Parental influence on the mental health-related behaviour of young people with mental illness: Young people’s perceptions

Abstract

Parents of young people with mental illness use a variety of strategies to try to positively influence young people’s mental health-related behaviours. Evidence suggests that these parents can influence young people’s well-being and mental health trajectories. However little is known about how young people perceive and are affected by the strategies parents use. In-depth qualitative interviews focussing on parental involvement in mental health were conducted with 26 young people with mental illness. The data were analysed using constant comparative analysis. Young people described parents as directly influencing their mental health-related behaviour through facilitative, persuasive and controlling practices. Young people’s behavioural and emotional responses to these practices were influenced by when the incident occurred; what they believed about the attitudes and motives behind their parents’ actions; whether they agreed in principle with the practices; the degree to which they accepted their parents’ authority and anticipated their own increasing autonomy; and whether other support was provided alongside the behavioural practices. Understanding how young people view their parents’ influence on their mental health-related behaviour under different circumstances is a vital step towards promoting the best possible parental support for these young people.

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Copyright © eContent Management Pty Ltd. Advances in Mental Health (2013) 12(1): 63–74.
Volume 12, Issue 1, October 2013 ADVANCES IN MENTAL HEALTH
Parental influence on the mental health-related behaviour of young
people with mental illness: Young people’s perceptions
Anne Honey*, Vikki FrAser*, GwynnytH LLeweLLyn*, PHiLiP HAzeLL+ And simon CLArke+
*Faculty of Health Sciences, Centre for Disability Research and Policy, University of Sydney, NSW,
Australia; +Sydney Medical School, University of Sydney, Sydney, NSW, Australia
Abstract: Parents of young people with mental illness use a variety of strategies to try to positively influence young
people’s mental health-related behaviours. Evidence suggests that these parents can influence young people’s well-being and
mental health trajectories. However little is known about how young people perceive and are affected by the strategies
parents use. In-depth qualitative interviews focussing on parental involvement in mental health were conducted with 26
young people with mental illness. The data were analysed using constant comparative analysis. Young people described
parents as directly influencing their mental health-related behaviour through facilitative, persuasive and controlling prac-
tices. Young people’s behavioural and emotional responses to these practices were influenced by when the incident occurred;
what they believed about the attitudes and motives behind their parents’ actions; whether they agreed in principle with
the practices; the degree to which they accepted their parents’ authority and anticipated their own increasing autonomy;
and whether other support was provided alongside the behavioural practices. Understanding how young people view their
parents’ influence on their mental health-related behaviour under different circumstances is a vital step towards promoting
the best possible parental support for these young people.
Keywords: young people, parents, families, qualitative research, social support, early intervention
The support parents provide for young people
who develop mental illness is of critical
importance. Internationally, around three quar-
ters of all lifetime mental disorders begin by the
mid-20s (Kessler et al., 2007). Youth mental
health is a significant concern in Australia, with
mental disorders accounting for 61% of the
non-fatal burden of disease for this age group
(Australian Institute of Health and Welfare,
2007). An increasing majority of young people
remain living in the parental home until at least
24 years of age (Australian Government Office for
Youth, 2009), thus parents are likely to play an
important part in the lives of many young people
with mental illness. Indeed, the importance of
parents and other carers and the need to appropri-
ately support them is increasingly being acknowl-
edged in mental health policy (Commonwealth
of Australia, 2009).
One of the highest priority needs identified
by carers of people with mental illness is the
need for knowledge and information, including
advice about strategies to use (Mental Health
Council of Australia, 2010). Interventions have
been developed to provide families with such
information and support (Lock & Le Grange,
2005; Lucksted, McFarlane, Downing, Dixon,
& Adams, 2012) and research has found
these, along with a diverse range of other fam-
ily interventions to be helpful for people with
mental illness, particularly in reducing symp-
toms and relapse. However, the critical compo-
nents of family treatments and the mechanisms
through which they work are unclear (Diamond
& Josephson, 2005; Kazdin & Nock, 2003).
Understanding the things parents do to try to
assist young people with mental illness and how
these strategies affect young people, is one way
to begin to unravel the link between family
interventions and outcomes.
Parents seek to influence young PeoPle’s
mental health-related behaviour
Research on the experiences of parents who have
a young adult son or daughter with mental illness
has shown that, along with providing emotional
and practical support, these parents also see influ-
encing the young person’s mental health-related
behaviour as an important part of their role.
This includes encouraging behaviour they believe
to be beneficial for the young person and their
mental health, such as attending and complying

Anne Honey et al.
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Little is known about how young people with
mental illness understand and experience the strate-
gies their parents use to influence their behaviour.
Studies to date have focussed primarily on the over-
all experience of illness and recovery or treatment
for young people, though some of these studies
mention parents’ influence on their behaviour, par-
ticularly in relation to young people seeking treat-
ment as a result of parents’ advice (de Haan, Peters,
Dingemans, Wouters, & Linszen, 2002; Lindsey
et al., 2006; McCarthy, Downes, & Sherman, 2008;
Tierney, 2008; Wisdom & Agnor, 2007). In a study
that examined communication between adolescents
with depression and ‘important adults’ including
parents, young people reported that adults ‘steadily
pushing’ them towards treatment, even in the face of
resistance and resentment, was effective (Draucker,
2005). Young people have also reported that their
parents advise them about activities like treatment
attendance and using coping strategies, and pro-
vide practical assistance, such as money, transport
and organising appointments (e.g., de Haan et al.,
2002; Lindsey et al., 2006; MacDonald, Sauer,
Howie, & Albiston, 2005; McCarthy et al., 2008).
There is also some evidence that parents can have
a negative impact, for example, by discouraging
treatment (e.g., Rorty, Yager, & Rossotto, 1993).
In these studies, however, young people’s reports of
their parents’ responses are incidental to the main
focus of the study so the detail and scope of young
people’s experiences are unknown.
It is increasingly being recognised that the dis-
tinctive profile of young adults with mental illness
needs to be taken into account when designing
and delivering mental health services (Barnett
& Lapsley, 2006). The importance of parents to
young people’s experiences is part of that profile.
Young people’s perceptions may differ from those
of a parent or observer, so it is critical that young
people’s perspectives, and the meanings they hold
that may shape their actions, are understood.
the Present study
This paper addresses the following research ques-
tions: (1) How do young people with mental illness
experience their parents’ influence on their men-
tal health-related behaviour? and (2) What factors
influence young peoples’ perceptions and responses?
with treatment, eating and exercising well, and
engaging in positive social behaviour and age-
appropriate activities like attending school or
work. Parents also seek to prevent behaviour they
see as detrimental to mental health and well-being,
such as self-harm, drug consumption, and socially
isolating, aggressive or criminal behaviour. They
report using a variety of strategies to achieve their
aims including: Praising and rewarding desirable
behaviour; reasoning and rational argument; per-
suading, coaxing and cajoling; overt monitoring;
using parental authority; threatening; and even
force (e.g., Honey & Halse, 2005; Honey, Alchin,
& Hancock, in press; Milliken & Rodney, 2003;
Sin, Moone, & Wellman, 2005). To date, evi-
dence is lacking as to the impact of these strategies
on young people. Listening to young people’s own
perspectives is an important aspect of understand-
ing this impact.
young PeoPle’s exPeriences of Parents’
influence on their behaviour
Given the developmental tasks of adolescence and
young adulthood, particularly the attainment of
autonomy, parents’ influence on young people’s
behaviour is likely to be a salient issue for young
people with mental illness. For typical adolescents
and those with health conditions, adolescence is
usually characterised by decreased parental super-
vision and involvement in health care (Gondoli,
1999; Sawyer & Aroni, 2005). Yet parents retain
a degree of authority, particularly while the young
person is financially dependent, which makes the
dynamics of providing support for health care
unique to the parent–young person relation-
ship. Parents of young people with health con-
ditions, whatever the origin and diagnosis, are
often characterised as overprotective but they can
be torn between the competing demands of pro-
tecting their child’s health and supporting their
increasing independence and autonomy (Sawyer
& Aroni, 2005; Williams, 2000). For parents of
young people with mental illness, the situation is
even more complex as the young person’s ability
to make their own decisions may be impaired or
may be seen by others to be impaired, resulting in
parents feeling the need to exercise greater influ-
ence over their behaviour.

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the study. The study was also publicised through
disability services at a number of universities via
newsletters. This wide ranging sampling technique
was used because young people with mental illness
are considered to be a notoriously difficult group
to access (Draucker, 2005). The final sample of 26
young people was recruited from: One adolescent
outpatient ward (N = 6); three early intervention
services (N = 5, N = 4, N = 1); one special purposes
school (N = 8) and two universities (N = 1 each).
The project was usually introduced to par-
ticipants by clinicians at the health services, who
obtained permission to pass contact details on to
the researchers. Some participants provided their
contact details after researchers presented the
project to a group of young people or responded
to a written invitation from the service provider.
All potential participants were contacted by tele-
phone and an interview time was organised if
the young person wished to participate. At the
interview meeting, the interviewer explained the
project to the young person again using a plain
English information sheet, answered any ques-
tions and obtained informed consent. Ethical
approval for the study was obtained from the
University of Sydney and the relevant Area Health
Services. Pseudonyms are used in reporting data
to protect participants’ privacy.
Data collection
Data were collected using in-depth qualitative
interviews. Qualitative interviewing is an appropri-
ate method for exploring how participants under-
stand their experiences and reconstruct events
in their lives (Rubin & Rubin, 2005). In-depth
interviews are needed when the research question
may involve conflicted emotions and complicated
perspectives and when issues are likely to require
explanation and elaboration (Johnson, 2001;
Rubin & Rubin, 2005). Following the responsive
interviewing model (Rubin & Rubin, 2005), an
interview guide was used containing a short series
of open-ended questions. Participants were first
asked to tell the story of what had happened since
they began having problems with their mental
health, with particular attention to the part played
by their parents. Other questions asked them to
think about parent actions that were particularly
methods
Study design
This study used a qualitative, inductive research
design to explore the subjective perspectives of
participants. In-depth interviews were analysed
using constant comparative analysis (Glaser &
Strauss, 1969). This is an appropriate method for
investigating how people understand their experi-
ences and how these understandings shape their
responses, especially in areas in which little research
exists (Schreiber & Stern, 2001). It enables the
researcher to put aside pre-existing assumptions
and develop constructs from the perspectives of
the people experiencing the phenomena.
Participants and recruitment
Rather than sampling from a particular diagnostic
group this study included young people who were
being treated for a range of different mental health
problems. A non-categorical approach is helpful
in looking beyond biomedical specifics to com-
monalities in social and psychological experiences
across conditions (Stein, Bauman, Westbrook,
Coupey, & Ireys, 1993; Stein & Silver, 1999) and
has been found to be useful with young people
with long-term physical conditions and disabili-
ties (Honey, Llewellyn, Schneider, & Wedgwood,
2010). It is a particularly appropriate approach
here given the relative frequency within this age
group of diagnostic uncertainty and changing and
multiple diagnoses and the evidence suggesting
that some family processes may be common across
disorders (Diamond & Josephson, 2005). In line
with the inductive study design, the salience of
diagnosis was regarded as an empirical question,
the answer to which should be allowed to emerge
in the inductive analysis.
Young people sampled for this study were
those in frequent contact with at least one par-
ent, defined as face-to-face or telephone contact
at least once per fortnight (Australian Bureau of
Statistics, 2006). The researchers identified and
contacted all mental health services in the Sydney
Metropolitan area that specialised in treating ado-
lescents, young people or first episode mental
illness and invited them to be part of the study.
At each service, clinicians were asked to invite all
clients who fit the study criteria to participate in

Anne Honey et al.
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helpful or unhelpful, and any changes they had
seen or wanted in their parents’ actions. The guide
provided a starting point for discussion, with the
interviewer following the participant’s lead by
encouraging them to expand on key ideas, provide
examples, and reflect on their own actions and feel-
ings about their experience of mental illness and
their parents’ involvement in this experience. This
allowed exploration of the breadth and depth of
participants’ views and allowed the interviewer
to pursue theoretical ideas suggested in previous
interviews in accordance with the approach used
(Glaser, 1978). Young people were interviewed by
the second author, who was of similar age to partic-
ipants, to reduce possible discomfort or reluctance
with older researchers. Interviews were recorded
with participants’ permission and transcribed ver-
batim. Transcripts were returned to participants for
correction and comment. Participants
also completed a written questionnaire
in which they reported their diagnosis
and provided demographic information.
Data analysis
Interviews were analysed using constant
comparative analysis (Glaser, 1978).
Concepts were developed from the data
rather than data being fit into pre-defined
categories, thus minimising precon-
ceived assumptions. Constant compara-
tive analysis involves the systematic
comparing of incidents and concepts to
create, refine, group and examine rela-
tionships between codes. Codes were
generated from the interview transcripts
and grouped into higher level categories
representing the diversity of young peo-
ple’s experiences of and responses to par-
ent practices. For example, several codes
that emerged from the data, including
giving advice, criticising and reasoning,
were identified as different ways parents
persuaded young people to change their
behaviour. Substantive codes conceptu-
alise the empirical substance of the data
(for example, anger), while theoretical
codes conceptualise the ways in which
the substantive codes are linked to each
other (for example, ‘anger’ as the response to a
parents’ ‘nagging’) (Glaser, 1992).
Data analysis was performed by the first author
and reviewed by the second author, with whom
codes, their interrelationships and the emerging
framework was discussed in detail to enhance the
validity of the interpretation. Conceptual satura-
tion (where no new concepts are emerging) was
achieved prior to completion of analysis of the
initial round of 26 interviews indicating that this
sample was appropriate and no additional recruit-
ment was necessary.
findings
Participants in this study were 26 young peo-
ple receiving treatment for a mental illness.
Demographic information about participants is
presented in Table 1.
tAbLe 1: PArtiCiPAnts
Age Range 15–24 years
Mean 17.4
Gender Male 9
Female 17
Living situation With both parents 14
With one parent 8
With neither parent 4
Occupation Secondary school student 16
University student 5
Employed full time 1
Employed casually (not
studying)
2
Not in employment or
education
2
Cultural background English second language
for one or both parents1
12
Self-reported diagnosis Depression 13
Anxiety 8
Eating disorder 6
Psychosis2 8
Other 1
More than one diagnosis 8
Time since first treated <1 year 11
1–4 years ago 9
>4 years ago 6
1Parents whose first language was not English came from a diverse
range of countries including Greece, Lebanon, Pakistan, Fiji, Tonga,
China, Hong Kong and the Philippines; 2No participants exhibited signs
of active psychosis during interviews.

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Young people’s perceptions of parents’
behavioural influence
Young people reported that their parents’ actions
in relation to their mental illness influenced
their behaviour, such as attending and comply-
ing with treatment, socialising, going to school
and church, self-harm, running away, and other
social and independent behaviour. Across the
variety of ways parents influenced young people’s
behaviour, three groups of practices emerged –
facilitative, persuasive and controlling practices,
each of which influenced young people’s behav-
iour through a different mechanism.
Facilitative practices made it easier for the young
person to engage in particular activities. Parents
researched, organised, paid for and transported
young people to treatment and leisure activities.
Oliver’s parents, for example, paid for his medi-
cation even though he was otherwise financially
independent, while Sam’s father helped him get
to school by waking him up, often repeatedly,
and driving him there. Facilitative practices were
generally appreciated by young people, who often
commented that these also demonstrated their
parent’s love and concern.
Persuasive practices encouraged or convinced
young people to behave in particular ways. Such
practices included monitoring, advice, and sug-
gestions about what young people could or
should do to facilitate their recovery or to cope
with their symptoms. For example, Eden’s mother
advised her about what to do at school if she felt
unwell, such as going for a walk to calm down,
or talking to a particular staff member. Parents
also rewarded some behaviour, for example, with
money or privileges, and encouraged others, par-
ticularly independent behaviour, by stepping back
from helping. For example, Caitlin reported that
her mother encouraged her to work for what she
wanted by not immediately buying her everything
she asked for. Where activities were seen as prob-
lematic, parents attempted to convince young
people to desist, for example, by overtly monitor-
ing them, explaining the negative impacts of the
activity on the young person and the family or
withdrawing privileges. In some instances parents
tried to persuade young people to change their
behaviour by criticising or belittling them about
negative behaviour. Wil, for example, described
how, when his father learned of his self-harm he
‘yelled at me and said ‘Why are you doing it? Are
you crazy?’
At their best, persuasive practices were seen as
helping or motivating the young person to do ‘the
right thing.’ Parry, who had anorexia, said that
knowing her mother was keeping an eye on her
eating and weight encouraged her to try to fol-
low her programme, while Georgia reported that
one of the most helpful things her mother did was
asking her to take her medication. However there
appeared to be a fine and subjective line between
helpful persuasion and negative interactions such
as ‘nagging,’ being ‘bossy’ and ‘staring over me all
the time.’ These interactions were seen as annoy-
ing, pointless and even detrimental, resulting in
avoidance or rebellion, such as when Felix stayed
at a friend’s home for several days to avoid inter-
acting with his mother.
Controlling practices involved parents using
their power and authority to ‘force’ the young per-
son to do some things or stop them from doing
other things. With these practices the young
person felt that their ability to choose their own
actions was removed. For example, several young
people talked about periods when they were very
unwell when their parents never left them alone
in order to prevent them from self-harm or run-
ning away. Others talked about parents con-
taining young people’s behaviour by physically
chasing them, blocking access to dangerous items
and even calling the police. In less acute situations
parents insisted that young people do things that
they were resistant to doing. As one participant
reported: ‘I have to come [to treatment] whether I
like it or not.’ In some instances, verbal insistence
was sufficient, while in others parents threatened
dire consequences for failure to comply. For sev-
eral of the young people with eating disorders
their parents overtly controlled their eating and
exercise. This was in accordance with the family-
based treatment approach used, the Maudsley
approach, in which parents are supported by
health workers to take control in the initial stages
of treatment (Lock & Le Grange, 2005).
Young people often recognised that it was in
their best interests to do things that they did not

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want to do, for example, go to school, socialise
or go to treatment. Even though Dana used to
get angry when her mother insisted on taking her
to psychiatrists and counsellors, she thought that
‘later on I’m going to look back and I’m going to
see that she was right all along.’ Others however
felt differently. For example, Darcie was angry
with her parents because ‘they don’t really let me
do anything, they kind of control my life.’
Whether a practice was regarded as facilita-
tive, persuasive or controlling was not solely
determined by the parent’s actual action, but by
the young person’s subjectivity. For example, tell-
ing a young person that it was time to take their
medication may be perceived as facilitative if the
young person wished to take it but had forgotten,
persuasive if the young person was ambivalent, or
controlling if the young person felt that they had
no choice but to comply.
There was considerable variation in both the
level of influence young people reported their
parents’ actions having and the feelings this
engendered. This was partly related to the type
of practices used: Facilitative practices were
almost universally condoned, while persuasive
and controlling practices were more controversial
as detailed above. Differences in young people’s
reactions did not, however, appear strongly related
to the type of behaviour parents were trying to
influence, such as treatment attendance and com-
pliance or other lifestyle issues such as going to
school or not drinking alcohol. Rather, they were
more strongly aligned with young people’s per-
ceptions of a number of contextual issues.
Factors influencing young peoples’
perceptions of their parents’ practices
Timing and outcome
In many instances young people reported that
their perspectives of their parents’ practices, par-
ticularly controlling practices, were different in
retrospect than they had been at the time. As Rafi
said of his mother’s controlling actions: ‘I thought
at the time that wasn’t the right thing, but now I
think it was the right thing.’ Conversely, another
participant said that, although at the time she
liked that her mother allowed her to stay at
home, in retrospect ‘she knew I was isolating
myself and she just let it be … I wish she’d
helped me a bit more.’ Differences were partly
to do with the progress of the illness, as young
people felt that they were able to see things more
clearly when they were less acutely unwell. Even
older participants who saw themselves as fairly
independent reported in retrospect that they had
needed their parents to get them to go to treat-
ment initially and at times when they were ‘in so
deep’ that they were unable to see the need for
or seek help themselves. The passage of time also
allowed young people to assess the effectiveness
of parents’ practices. Vince, for example, said
that although some of his parents’ actions were
‘annoying’ at the time, he ‘wouldn’t really change
it, because it worked.’
Agreement in principle
Young people reacted more positively to their
parents’ behavioural influence when they under-
stood and agreed in principle with what their
parents were trying to do. Felicity, for example,
saw her parents’ close supervision and insistence
on eating as helpful because she agreed that eat-
ing was necessary but didn’t think she would
‘have the discipline yet to eat myself.’ Two
other girls with eating disorders, however, who
believed that they could recover on their own,
resented their parents’ similar actions and saw
them as intrusive. Young people often agreed
with what parents saw as beneficial even while
not wanting to comply due, for example, to lack
of motivation or social anxiety. For example, one
young woman reported that her mother insisting
she attend social events ‘really helps in the long
term even though in the short term you really
don’t want to.’
Acceptance of authority
The degree to which young people accepted
their parents as having authority over them and
their actions was an important factor influenc-
ing their reactions, particularly to parental con-
trolling practices. Although individually based,
this appeared related to demographic factors.
Younger participants who were still at school and
living with their parents and young people from
non-western cultures often took it for granted

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that their parents would make decisions such
as whether to see a health professional. While
they sometimes complained about their parents
making them do things, they usually expected
to comply. More independent young people,
who were no longer accustomed to yielding to
parental authority, tended to report less control-
ling practices, and were more likely to report
being persuaded or ‘nagged.’ For example, one
young man reported that his mother had per-
sistently ‘kept at’ him to see a psychologist until
‘I just gave up and went.’ When these young
people reported attempts by parents to use
authority they described them as ineffective and
inappropriate.
Graded autonomy
Behaviour focussed practices, and particularly
controlling practices, tended to be better tolerated
when young people believed that the situation
was temporary. Nine young people mentioned
that their parents had graded the responsibil-
ity and freedom that they were allowed as their
mental health improved. Participants saw this as
important in order for them to grow and mature
and for their lives to be ‘more normal, more like
it should be.’ One young man, for example, said
that his mothers’ restrictions on his activities
made him feel ‘like a kid’ but that her reassur-
ance that ‘it’s only a matter of time until you
get back to normal’ had encouraged him. Cara
said that knowing improvement would result in
greater self-determination acted as an incentive
to ‘get better to get more freedom.’ Participants
saw being given increased autonomy with age as
beneficial and appropriate despite the presence
of mental illness. On the other hand, a couple of
young people suggested that the mental illness
had hindered the relationship with their par-
ents from developing into a more equal one as
would be appropriate for their age, and that their
parents still treated them ‘like a child.’ Time and
again, the young people interviewed raised the
importance of their progress towards adulthood.
Participants saw being treated age appropri-
ately and ‘normally’ as ‘a good sign,’ a reassur-
ance that their parents saw them as improving
and maturing.
Behavioural practices used in conjunction
with support
Many of the young people who expressed high
overall satisfaction with their parents’ support also
described parents who used numerous controlling
and persuasive practices. However each of these
young people reported that their parents also used
facilitative practices as well as a wide variety of other
strategies, including high levels of emotional and
environmental support. Young people who reported
parent practices that were solely or primarily con-
trolling or persuasive tended to be more resentful
and resistant to these practices. Controlling prac-
tices in particular needed to be used in conjunction
with other strategies to soften their impact and help
young people to cope with the loss of control, for
example, listening to and sympathising with the
young person’s feelings and trying to minimise the
disruption caused. Teuila, for example, said that her
parents would not allow her to go out alone when
she was very unwell, but when possible would
accompany her wherever she wished to go.
Attribution of parents’ motives
Young people’s reactions to parents’ behavioural
influence were shaped by how young people inter-
preted the feelings, beliefs and attitudes behind
parents’ words and actions. For many young peo-
ple, parents’ attempts to influence their behaviour
were seen as indicators of their love and concern.
Young people who saw things this way were more
likely to feel positively about parents’ actions even
if they might find the actions annoying. As one
participant put it ‘I’d rather that she does than not
do anything at all. Because, then at least I know
that she cares.’
Young people also responded more positively
when they saw their parents’ actions as rational,
well considered, non-punitive and reflecting con-
fidence that the young person would recover. For
example, one young man did not want to con-
tinue treatment but accepted his mothers’ expla-
nation that he had improved and she did not want
him having to start all over again. Conversely,
parents’ actions were not well received when they
were seen as arbitrary or emotion based. One
participant found it confusing and unfair that
her parents kept changing their rules and did not

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explain these to her, giving reasons like ‘because I
say so.’ Where parents’ practices were accompa-
nied by expressions of strong distress or anger, or
when they were seen as reflecting critical, blaming
or pessimistic attitudes, young people often felt
guilty, upset, and under pressure, and they typi-
cally felt that this did not help them change their
behaviour. Briana, for example, described her
parents’ advice having the opposite effect from
what was intended: ‘They keep going on about
the future and how I won’t get anywhere if I don’t
do something about, like, not acting strange and
then I get worried about the future and then I get
even more strange.’
Young peoples’ feelings about their parents’
practices were strongly influenced by their beliefs
about whether the parent understood them and
took their perspectives into account. When this
was not the case, participants tended to see par-
ents’ actions as intrusive, uninformed and inap-
propriate. Jen, for example thought things would
improve if her mother ‘just let up on what it says
in the textbook and actually listened.’ Alison was
dismissive of her mothers’ advice because ‘every
time she opens her mouth it shows me that she
doesn’t understand.’ Parents saying they under-
stood was clearly not enough and sometimes
prompted reactions such as: ‘you’ve got no clue.’
Instead, parents who were seen as
understanding listened to young
people and demonstrated their
understanding by their actions,
such as being ‘supportive about
situations they could get angry
about’ and respecting young peo-
ple’s wishes.
Illness related and demographic
factors
An interesting feature of the data
was that commonly researched
factors such as diagnosis, age and
illness duration did not emerge as
direct influences on how young
people experienced and reacted
to parental behavioural influence.
While these factors were often rel-
evant, their influence was largely
indirect, occurring through their impact, in
interaction with other factors, on the six contex-
tual variables. For example, for some participants
the egosyntonic nature of anorexia may have
contributed to a lack of agreement in principle
with parent practices; age was one influence on
acceptance of authority; and longer illness dura-
tion had in some, but not all, instances lead to
improvements in young people’s perceptions of
parental understanding. Similarly, other factors
such as family history and previous relationships
are also likely to influence young people’s per-
ceptions of the contextual factors. For example,
past or current abuse or maltreatment within the
family, while not reported by any participants in
this study and not overtly explored with them,
would be likely to have a strong impact on how
young people responded to parent practices. The
hypothesised relationship between these factors is
depicted in Figure 1. In some instances, demo-
graphic and illness specific factors did appear to
affect the strategies parents chose, such as control-
ling practices for anorexia; and also the behaviour
parents sought to influence, for example, going
to school for younger participants and using cog-
nitive strategies for young people with anxiety.
However, factors influencing parents’ choice of
strategies is beyond the scope of this study.
FiGure 1: inFLuenCe oF beHAViour FoCussed PArentAL PrACtiCes on
younG PeoPLe

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Volume 12, Issue 1, October 2013 ADVANCES IN MENTAL HEALTH 71
Limitations
Being a qualitative study, the findings presented
provide insight into participants’ perceptions. The
applicability of findings to other groups of young
people with mental illness should be assessed by
reference to the description of participants pre-
sented. In particular, although participants came
from a number of cultural backgrounds, all lived
in or near Sydney. Experiences of young people
living in other countries and in rural or remote
areas may differ. For example, community knowl-
edge about and attitudes towards mental illness
are likely to influence both the practices par-
ents use and how they are interpreted by young
people. As with most research using volunteers,
there is also the possibility that young people who
agreed to participate in this study differed from
those who did not.
The current paper presents a detailed exami-
nation of young people’s perspectives on their
parents’ direct influence on their behaviour.
Other parent strategies that primarily influence
young people’s thoughts and feelings, such as
providing emotional support, can also indirectly
influence behaviour. However these are not the
focus of this paper.
discussion
This study indicates that young people’s behav-
iour is influenced to varying degrees by the
facilitative, persuasive and controlling practices
adopted by their parents for this purpose. How
they experience and respond to these practices
appears to be shaped by the passing of time, the
degree to which young people agree with the
practices in principle and accept their parents’
authority, their perceptions of the impact of these
practices on their current and future autonomy,
whether parents also provide other types of sup-
port, and the attitudes and motives young people
attribute to their parents’ actions. For mental
health professionals, this understanding of the
dynamics of parental influence on young people’s
behaviour is important, especially because of the
critical role parents can play in initiating and
supporting their participation in professional
treatment (Wilson, Rickwood, Bushnell, Caputi,
& Thomas, 2011).
Many of the young people in this study recog-
nised that their parents’ influence on their behaviour,
even when it went against their current inclinations,
could be helpful under certain conditions. This is
consistent with Draucker’s (2005) finding that
adults continuing to push resistant young people
with mental illness was seen in retrospect as ulti-
mately helpful. It is clear from the current study
however, that simply pushing is not enough: The
circumstances and the ways in which parents seek
to influence behaviour are important to how young
people respond. In this regard, young people’s per-
spectives are consistent with general parenting liter-
ature. For example, while setting and enforcing rules
and limits on behaviour has been associated with
social competence, psychological control, such as
invalidating young people’s feelings and experiences
and making them feel guilty has been linked with
negative outcomes, especially internalised problems
(e.g., Barber, Olsen, & Shagle, 1994). The factors
related to young people’s positive experiences of
their parents’ behavioural influence are also com-
patible with an authoritative parenting style (e.g.,
Baumrind, 1991) consisting of both high demand
and high support, which has been strongly linked
to positive outcomes for adolescents such as school
performance, adjustment and behaviour (Steinberg,
2001). Parents who adopt this style maintain lim-
its and boundaries but are willing to discuss and
explain these and they encourage maturity, respon-
sibility, expression of opinions and age-appropriate
independence. The present study suggests that
authoritative parenting may have a positive impact
on young people’s willingness to accept behavioural
direction related to illness management due to
positive perceptions of the contextual factors. Some
researchers in the area of parent–child attachment
have conceptualised parenting along dimensions
of care and protection, with high perceived levels
of care and low perceived levels of overprotection/
control being regarded as optimal (e.g., Wilhelm,
Niven, Parker, & Hadzi-Pavlovic, 2004). This is
consistent with the importance to young people
of parents providing emotional support in addi-
tion to behavioural influence, and reinforcing that
increased levels of protection are temporary while
continuing to facilitate age-appropriate responsibil-
ity wherever possible.

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72
Young people’s perspectives also resonate with
research on expressed emotion (EE) and family
interventions. Many of the parent practices expe-
rienced as negative by young people may be the
behavioural consequences of the critical family
attitudes and over-involvement that EE literature
has linked to mental illness exacerbation (Butzlaff
& Hooley, 1998; Vaughn & Leff, 1976). While
family interventions are shown to influence EE
and outcomes for people with mental illness, there
is currently little evidence about the mechanisms
for change (Kazdin & Nock, 2003). The current
research suggests a potential for family interven-
tions to change both the practices parents adopt and
the contextual factors that influence young people’s
response to those practices. For example, psycho-
educational approaches usually include a focus on
helping parents to attain and communicate a realis-
tic and non-critical understanding of mental illness.
Previous general population research has sug-
gested that the influence young people see their
parents as having over them (as opposed to the
influence parents try to exert) is primarily associ-
ated with young people’s perception of the rela-
tionship as positive and supportive (McElhaney,
Porter, Thompson, & Allen, 2008). This study
highlights the interrelationship between the
dimensions of behavioural influence and support
for young people with mental illness. Supportive
activities, such as demonstrating concern, talking
about problems, spending time together, cheering
the young person up and conveying love through
treats and freedoms (Barber, Stolz, & Olsen,
2005; McNeely & Barber, 2010), appeared to
soften the emotional impact of parents exerting
behavioural influence, help shape positive inter-
pretations of this as being done out of love and
concern and improve young people’s willingness
to accept behavioural direction related to illness
management.
Young people’s perspectives also emphasise
the importance of having a sense of the conti-
nuity of the developmental trajectory towards
full adulthood despite the presence of mental
illness. Mental illness can delay or even prevent
the expected transitions of early adulthood, such
as becoming financially independent and mov-
ing out of home (Stein & Wemmerus, 2001).
It can also change parents’ and young people’s
expectation of the appropriate balance between
autonomy and protection, thus disrupting the
normalised trajectory of authority. Young people
in this study, like their counterparts with physical
health conditions (Berntsson, Berg, Brydolf, &
Hellstrom, 2007) report experiencing well-being
when they are allowed to prepare for living a nor-
mal life integrated into society including auton-
omy in health care and in their everyday lives.
Implications
Understanding young people’s experiences is
a crucial step for developing empirically based
guidelines for parents. Further research is needed
to investigate, preferably in a quantitative longitu-
dinal design, the parent practices and contextual
variables associated with desirable and measur-
able outcomes for young people, such as positive
health-related behaviour, reduced symptoms and
enhanced well-being. Identifying the influence of
interventions on both parent strategies and con-
textual variables will help to isolate the processes
underlying the impact of family interventions.
Potentially relevant factors such as gender, socio-
economic status and diagnosis, which did not
emerge as directly important in this qualitative
analysis, need further exploration using quantita-
tive methods.
While guidelines for parents cannot be devel-
oped directly from a small sample study such as
this, perceptions of young people who partici-
pated in this study suggest the following consid-
erations for parents wishing to influence the
behaviour of young people with mental illness:
(1) Developmental needs: Where parent prac-
tices interrupt the autonomy/authority tra-
jectory the young person should be included
in the discussions around this and assured of
its temporary and non-punitive nature;
(2) Concurrent support: Persuasive and control-
ling practices should go hand in hand with
facilitative practices and other forms of sup-
port which demonstrate: (a) a willingness to
help and facilitate desired behaviour, not just
direct it; and (b) a concern with young peo-
ple’s feelings and environments, not just their
behaviour;

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(3) Positive attitudes: Increased parental
understanding about the illness, including
non-critical conceptualisations, and about
the young person as an individual, through
seeking and listening to their perspectives,
may facilitate positive responses from young
people to parents’ attempts to influence
behaviour;
(4) Clarity of rationale: The communication of
clear rationale for and predictable and calm
use of parent practices is needed so that these
can be interpreted as rational, considered and
designed to assist young people, rather than
arbitrary, emotion-driven or punitive;
(5) Contextual factors: Issues such as pre-exist-
ing family relationships and family culture
in relation to parental authority and young
person autonomy should be considered in
formulating strategies.
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Received 17 April 2013 Accepted 08 September 2013