Serious mental illnesses (SMIs), such as schizophrenia and other psychotic disorders, cause substantial functional impairment, increased mortality risk, high familial distress, and economic burden. First-episode psychosis (FEP), typically occurring in adolescence and early adulthood, is particularly vulnerable. The period after FEP is critical for determining illness trajectory, requiring comprehensive and coordinated intervention. However, individuals with FEP often discontinue treatment prematurely, potentially due to factors like lack of meaningful support, dissatisfaction with FEP services, or insufficient trauma-informed and culturally-relevant care. Lack of family involvement predicts treatment disengagement. Caregiver engagement is crucial for securing services, navigating system barriers (e.g., delays in FEP program enrollment, lack of high-quality continuing care), and supporting the individual's recovery. Caring for individuals with SMI is challenging for caregivers, leading to various mental health conditions. Addressing caregiver needs requires psychoeducation, resource navigation, and emotional support. Family peer interventions, delivered by peer professionals with lived experience, can effectively fill this need by reducing caregiver distress, increasing self-efficacy, and supporting service navigation. However, research on family peer interventions for caregivers of adults with SMI is limited. This study evaluates the Family Connectors (FC) program, an adaptation of the Parent Connectors program, for caregivers of young adults discharged from FEP programs. The collaborative adaptation process between researchers and family peer professionals (Family Connectors or FCs) is documented to inform future support efforts for families of individuals with SMI and provide a model for improving peer support services for unique groups.

The literature highlights the significant challenges faced by caregivers of individuals with serious mental illness (SMI), particularly those experiencing first-episode psychosis (FEP). Studies show a strong correlation between caregiver involvement and treatment adherence in individuals with FEP. However, there's a lack of readily available high-quality continuing care options following discharge from FEP programs. Existing research on the effectiveness of peer-to-peer family support interventions for caregivers of adults with SMI is limited and shows variable results across outcomes. This research gap underscores the need for further investigation into tailored interventions that address the unique needs of this population. The existing literature emphasizes the need for comprehensive support that encompasses psychoeducation, resource navigation, and emotional support for caregivers. Peer-to-peer support models are considered a promising avenue for filling this need, offering a direct and personal connection that can enhance caregiver well-being and foster sustained engagement.

This study adapted the evidence-based Parent Connectors (PC) program for caregivers of school-aged children with emotional and behavioral conditions into the Family Connectors (FC) program for caregivers of young adults discharged from FEP programs. The adaptation was a collaborative effort involving PC program directors, the research team, and five FCs (family peer professionals). The process was iterative, taking place over three months and involving several meetings. The goal was to maintain the theoretical underpinnings of the Theory of Planned Behavior while modifying it for a new population. FCs received intensive manualized training, similar to the PC program, covering communication skills, empowerment, boundaries, psychoeducation (including on psychosis and the OnTrackNY program), ethics, and confidentiality. The distinction between intervening and providing resources/encouragement was emphasized. FCs conducted weekly telephone calls with caregivers for six months, aiming to promote caregiver well-being and service engagement. Weekly meetings with an FC coach (mental health professional) provided case support. The research team and FCs engaged in an ongoing partnership with open communication about program implementation and evaluation. A formalized review process involved dividing the manual into ten sections and having the FCs reflect on each section's applicability to caregivers of young adults with SMI. This process documented adaptations based on a framework differentiating context, content, and training/evaluation modifications. The team collaborated on manuscript preparation.

Adaptations were primarily content modifications, with no context modifications deemed necessary after the initial adaptation to the SMI population. Content modifications included: * **Tailoring/Tweaking/Refining:** Increased focus on factors specific to caring for adult loved ones (long service history, legal limitations on caregiver involvement, inconsistent clinician inclusion of caregivers, need for partnerships); increased training on SMI-related factors (anosognosia, symptom chronicity, tailored emotional support); increased emphasis on safety and crisis planning, including education on structural supports; and increased focus on cultural considerations. * **Integrating Another Approach:** Integration of the LEAP (Listen-Empathize-Agree-Partner) method to improve caregiver-loved one relationships. * **Adding Elements:** Addition of an online resource hub for ongoing caregiver support after program completion; recommendation for a future caregiver support group. * **Lengthening/Extending:** Extension of the intervention period for caregivers facing crises or service delays. The only training and evaluation modification was the addition of a weekly peer-to-peer meeting for FCs to address burnout, process triggers, and receive peer support. The 6-month time frame was extended in some cases due to ongoing crises or service access challenges. The FCs noted the importance of addressing caregiver grief, trauma, shame, and isolation; emphasizing the chronic and unpredictable nature of SMI; and providing education on structural supports (988, AOT, PADs). The online resource hub was deemed essential to fill the gap in community support for caregivers of adults with SMI. The LEAP method proved helpful in cases of anosognosia. The peer-to-peer supervision meetings were considered crucial for FC well-being and retention.

This study is the first to detail the adaptation process of a family peer support intervention for a specific population. The low-magnitude changes made to the FC program highlight its flexibility and suitability for adaptation to diverse groups. The study's findings largely support tailoring/tweaking/refining as the most effective adaptation strategy. The increased emphasis on cultural considerations aligns with research showing disparities across racial groups in access to care and treatment for FEP. Lengthening the program in certain cases was deemed necessary due to system-level barriers and crisis situations. The addition of an online resource hub addressed a critical gap in community support for this population. The integration of the LEAP method proved beneficial. The addition of peer-to-peer supervision was instrumental in supporting FC well-being and retention. The study's limitations include the sample's geographic location and size, lack of direct caregiver feedback (addressed in an ongoing qualitative study), and the limited representation of caregivers with FEP experience on the team.

This study demonstrates a successful adaptation of the Parent Connectors program for caregivers of young adults with SMI. The collaborative adaptation process, guided by the lived experience of family peer professionals, resulted in a more relevant and effective intervention. The findings highlight the importance of ongoing collaboration, flexibility, and culturally sensitive approaches in developing peer support services. Future research should focus on standardizing the adaptations, exploring different intervention timepoints (e.g., program intake or first crisis), identifying optimal integration methods into FEP programs, and evaluating cost-effectiveness.

The study's limitations include the recruitment of families from a single FEP program in New York, limiting generalizability. The research team and FCs were primarily based in New York and lacked broad representation of experiences with FEP programs. The sample size of caregivers was relatively small, further limiting generalizability. Direct feedback from caregivers was not yet available at the time of this publication.