Enduring challenges and sustaining hope: family resilience in caring for adolescents with mental disorders

¹Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia, ²Department of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia, ³Department of Nursing, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia

^&Corresponding author
Nor Afni Oktavia, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia

Introduction    

Mental disorders among adolescents have become a significant global public health concern, affecting not only individuals but also their families. Adolescents with mental health conditions often require long-term care, placing substantial emotional, social, and economic demands on family caregivers. In many contexts, particularly in low- and middle-income settings, families serve as the primary source of care, making their role central to supporting recovery and maintaining daily functioning [1-3]. Caring for adolescents with mental disorders is frequently associated with complex emotional experiences, including stress, uncertainty, and psychological burden [1,4]. Previous studies have shown that family caregivers often experience persistent emotional strain and difficulties adapting to their roles [1]. They may also face limited access to mental health services, financial constraints, and social stigma, which can further affect their well-being and ability to provide sustained care [5-7]. These challenges may become particularly pronounced when mental health conditions require prolonged support and supervision.

Despite these difficulties, families may develop adaptive responses that enable them to manage adversity and maintain functioning. Evidence indicates that coping strategies and perceived social support can contribute to positive adaptation and resilience among families facing prolonged health-related challenges [8,9]. Meaning-making may further help families reinterpret adversity constructively and strengthen psychological adjustment [10]. Family resilience refers to the capacity to adapt, endure, and reorganize in response to adversity [11]. Importantly, resilience is increasingly understood as a dynamic and relational process shaped by interactions among individual, family, and contextual factors [8,9].

Nurses play an important role in supporting families of adolescents with mental disorders, particularly in community and mental health settings. As frontline healthcare providers, nurses may provide psychosocial support, psychoeducation, and interventions aimed at strengthening caregivers' capacity to manage emotional and practical challenges [12]. Psychoeducational interventions have been shown to improve caregivers' understanding of mental illness, enhance coping strategies, and reduce perceived burden [13]. Evidence from systematic reviews also indicates that psychosocial and community-based interventions can improve psychological well-being and social functioning among individuals and families affected by mental health conditions [14]. Such interventions may also strengthen adaptive capacities and emotional regulation within families [12,13]. Understanding caregivers' experiences is therefore important for informing family-centered mental health services and strengthening nursing practice [13].

However, existing studies often examine caregiving burden, social support, or resilience as separate constructs, with limited integration of these dimensions within the experiences of families caring for adolescents with mental disorders. Recent evidence suggests that adaptation within families is multidimensional and influenced by family functioning, socioeconomic conditions, and relational dynamics, yet many studies continue to address these factors separately [15]. Moreover, qualitative evidence examining how emotional adaptation, social and structural challenges, and future-oriented hope interact within the caregiving experience remains limited. Emerging qualitative studies indicate that resilience develops dynamically through responses to ongoing challenges, emotional experiences, and meaning-making processes, highlighting the need for contextually grounded research [16,17]. This study aimed to explore the experiences of family caregivers of adolescents with mental disorders, with particular emphasis on emotional adaptation, social support, barriers, and future-oriented hope as dimensions of family resilience.

Methods     

Study design: this study employed a qualitative descriptive approach to explore the experiences of family caregivers of adolescents with mental disorders. A qualitative descriptive design was selected because the study sought a direct and contextually grounded account of caregivers' experiences, perceptions, and responses to caregiving challenges, rather than a phenomenological interpretation of the essential meaning of lived experience.

Settings: this study was conducted in Banjarmasin, South Kalimantan, Indonesia, an urban setting where families commonly serve as the primary caregivers for adolescents with mental disorders due to limited specialized mental health resources. Participants were recruited from community and healthcare settings where adolescents with mental disorders received ongoing care. Recruitment and data collection were conducted between January and December 2025.

Participants: a total of 39 family caregivers contributed data to the study. Twenty-one family caregivers were recruited using purposive sampling for in-depth interviews, while 18 additional family caregivers were recruited separately for focus group discussions (FGDs) and were not included among the 21 interview participants. The FGD participants were divided into three groups of six participants each. Participants were recruited from community and healthcare settings in Banjarmasin, Indonesia, where adolescents with mental disorders were receiving ongoing care. Participants were selected to provide rich information relevant to the study objectives. Eligibility criteria included: (1) being a parent or primary family caregiver of an adolescent diagnosed with a mental disorder; (2) having active involvement in the adolescent's daily caregiving for at least six months; (3) being aged 18 years or older; and (4) being willing and able to provide informed consent and participate in an interview or FGD. Caregivers who were not directly involved in daily care or were unable to communicate effectively during data collection were excluded. The 21 in-depth interview participants were mothers, while fathers contributed complementary perspectives through the separate FGDs.

Phenomenon of interest: the primary phenomenon of interest in this study was family resilience in caring for adolescents with mental disorders, explored through participants' experiences. Key domains examined included emotional experiences and adaptation, perceived social support, caregiving challenges, stigma, and future-oriented hopes related to adolescent recovery and independence. Relevant contextual characteristics, including caregiver socio-demographic background (age, gender, education, marital status, and relationship to the adolescent), duration of caregiving, and adolescents' age, were also documented to support interpretation of participants' experiences. Adolescents were considered eligible if they had a clinically diagnosed mental disorder, as reported by family caregivers based on prior assessment or treatment by healthcare professionals. As this was a qualitative descriptive study, no quantitative predictors, confounders, effect modifiers, or exposure interventions were formally measured. Instead, the study explored how contextual, relational, and experiential factors shaped family resilience within the caregiving process.

Data sources: data were collected through 21 in-depth interviews and three focus group discussions (FGDs) involving 18 additional participants, with six participants in each FGD. The in-depth interviews explored family caregivers' personal experiences, including emotional responses, coping strategies, and challenges encountered during caregiving. FGDs were used to gain a collective understanding of family experiences, including support dynamics and family roles. A semi-structured interview guide, developed based on the research objectives, was used to facilitate data collection. All interviews and discussions were conducted in comfortable and supportive settings, audio-recorded with participants' consent, and transcribed verbatim. Participants' identities were protected through data anonymization.

Bias: several measures were undertaken to minimize potential sources of bias. To reduce selection bias, purposive sampling was used to recruit participants with direct and substantial caregiving experience relevant to the study objectives, while including caregivers from both community and healthcare settings to capture diverse perspectives. To minimize response bias, interviews and focus group discussions were conducted in private and supportive environments, and participants were assured of confidentiality and anonymity to encourage open and honest sharing of experiences. To address researcher and interpretive bias, reflexive thematic analysis was applied with continuous reflective note-taking throughout data collection and analysis to enhance awareness of researchers' assumptions and preconceptions. Data source triangulation through the use of both in-depth interviews and focus group discussions was employed to strengthen credibility and reduce reliance on a single source of information. In addition, maintaining an audit trail of methodological and analytical decisions supported transparency and dependability of the findings.

Study size: the study size was determined based on data adequacy in qualitative research, with recruitment continuing until sufficient depth and variation in the data were achieved. The in-depth interview sample consisted of 21 purposively selected family caregivers who provided rich and relevant information about caring for adolescents with mental disorders. An additional 18 family caregivers participated in three FGDs of six participants each to broaden and contextualize the range of perspectives. Thus, 39 family caregivers contributed data overall, while the socio-demographic characteristics presented in Table 1 refer specifically to the 21 in-depth interview participants.

Data analysis: as this was a qualitative descriptive study, no statistical analyses were performed. Data were analyzed using reflexive thematic analysis following Braun and Clarke [18]. NVivo (version 15) was used to assist in organizing and managing the data. The analysis followed six phases: (1) familiarization with the data through repeated reading; (2) generation of initial codes; (3) grouping related codes into preliminary themes; (4) reviewing and refining themes through a reflective process; (5) defining and naming themes; and (6) integrating participant quotations into thematic narratives. Initial codes were synthesized and integrated into three overarching themes representing the overall family caregiving experience. The analysis was conducted iteratively by continuously comparing the data and emerging themes to ensure consistency and depth of interpretation.

Researcher reflexivity: the first author, a PhD candidate in health sciences, led data collection and initial analysis. The co-authors included an academic in medicine and health sciences and a nursing academic, providing complementary disciplinary perspectives during interpretation. None of the researchers had a prior professional, clinical, academic, or personal relationship with the participants or the recruitment settings. Reflexive notes were maintained throughout data collection and analysis to identify and critically examine researchers' assumptions, preconceptions, and potential influence on interpretation.

Rigor (trustworthiness): several strategies were employed to ensure the trustworthiness of the study. Credibility was enhanced through data source triangulation, including both in-depth interviews and FGDs. Dependability was supported by systematically documenting all stages of the research process, from data collection to analysis. Confirmability was supported through the use of reflective notes to enhance awareness of researcher assumptions during data interpretation. Transferability was strengthened by providing rich and detailed descriptions of the research context and participant characteristics, allowing readers to assess the applicability of the findings to other settings.

Ethical considerations: ethical approval for this study was obtained from the Medical Research Ethics Committee, Universitas Muhammadiyah Banjarmasin (Reference KEPK: 0128226371). The study was conducted in accordance with the Declaration of Helsinki. All participants received clear information regarding the study objectives, procedures, voluntary nature of participation, and their right to withdraw at any stage without consequence. Written informed consent was obtained from all participants before participation in interviews or focus group discussions. To protect participants' privacy and confidentiality, all personal identifiers were removed from transcripts, and pseudonymous participant codes were used during analysis and reporting. Audio recordings and research data were securely stored and accessed only by the research team.

Results     

Participants: a total of 39 family caregivers contributed data to this study. Twenty-one family caregivers participated in in-depth interviews and were purposively recruited from community and healthcare settings in Banjarmasin, Indonesia, between January and December 2025. An additional 18 family caregivers participated in three separate FGDs, with six participants in each group; these FGD participants were not included among the 21 interview participants. All 21 in-depth interview participants met the eligibility criteria as primary family caregivers of adolescents with clinically diagnosed mental disorders and were mothers. Fathers contributed additional perspectives through the separate FGDs.

Descriptive data: among the 21 in-depth interview participants, ages ranged from 39 to 57 years, with educational backgrounds including primary school, junior high school, senior high school, and university education. All were married and had caregiving experience ranging from six months to four years and nine months. The adolescents receiving care were aged between 12 and 18 years. Detailed socio-demographic characteristics of the in-depth interview participants are presented in Table 1; the 18 additional FGD participants are not included in this table.

Outcome data: the primary phenomenon explored was family resilience in caring for adolescents with mental disorders. Reflexive thematic analysis identified three overarching themes representing participants' experiences: (1) emotional experiences and family adaptation, (2) social support as a foundation of family resilience, and (3) barriers and future hopes (Figure 1).

Main result

Emotional experiences and family adaptation: this theme captures the dynamic emotional experiences of families throughout the caregiving process, from the initial recognition of the adolescent's condition to long-term care. Emotional responses were not static but evolved over time, shaped by caregiving demands and the meaning families attached to their roles.

Emotional trajectories in caregiving: families described the early phase of caregiving as emotionally overwhelming, marked by shock, sadness, confusion, and uncertainty. These reactions emerged when families first became aware of the adolescent's condition and continued to reappear throughout the caregiving process. "At that time, when I first found out about my child's condition, I felt like I was in shock... I was sad, confused, and didn't know what to do" (P3). Caregivers emphasized that emotional experiences were not linear but fluctuated over time, depending on the adolescent's condition and daily challenges. This indicates that emotional responses are an ongoing and integral part of caregiving.

Long-term emotional strain: caregiving was also associated with sustained emotional pressure and fatigue. Families described persistent worry, mental exhaustion, and a constant need to remain alert, reflecting the chronic nature of caregiving demands. "Sometimes I feel exhausted even when I just wake up... because my mind immediately goes to my child, and I worry that something might happen again" (P1). The lack of adequate time for emotional recovery further intensified this strain, suggesting that caregiving functions as a long-term source of psychological stress for families.

Emotional adaptation and parental responsibility: despite experiencing ongoing emotional challenges, families demonstrated gradual emotional adaptation. Caregivers reported learning to regulate their emotions, becoming more patient, and adjusting their responses to the adolescent's condition. "I have learned to control my emotions... not because I don't feel angry, but because this is my child and I have to be strong" (P12). This adaptation was closely linked to a strong sense of parental responsibility, which reinforced caregivers' commitment to continue providing care despite emotional exhaustion. These findings indicate that emotional adaptation is shaped not only by coping strategies but also by the meaning attached to the caregiving role.

Social support as a foundation of family resilience: this theme highlights social support as a key resource that enables families to sustain caregiving under ongoing emotional and practical demands. Support was derived from both informal and formal sources and influenced how caregivers managed stress and maintained resilience.

Support from immediate family: immediate family members were described as the primary source of support in caregiving. This support included sharing caregiving responsibilities, joint decision-making, and emotional reassurance, which helped reduce the burden on the primary caregiver. "When I feel tired, my husband takes over... at least I don't feel alone, he always supports and helps me" (P4). The presence of supportive family members strengthened a sense of togetherness and enhanced families' capacity to cope with caregiving challenges.

Emotional and moral support from the social environment: beyond the immediate family, support from neighbors, friends, and religious figures was also perceived as meaningful. This support was mainly emotional, including encouragement, empathy, and reassurance, which helped caregivers cope with stress. "My neighbors often tell me to stay patient and strong... even that alone makes me feel calmer" (P6). Such support reduced feelings of isolation and reinforced caregivers' belief that they were not facing the situation alone.

Involvement of community and healthcare providers: families also emphasized the importance of support from community services and healthcare professionals. Clear explanations, guidance, and empathetic communication from healthcare providers helped caregivers better understand the adolescent's condition and reduced uncertainty. "When the nurse explained everything patiently... I understood better and didn't feel as panicked anymore. I come from a rural area, so I didn't really understand before... but the nurses and doctors here are kind" (P13). However, limited access and inconsistent services were identified as challenges, indicating that the availability and quality of formal support significantly influence caregiving experiences.

Barriers and future hopes: this theme reflects the dual realities faced by families, where caregiving is shaped by ongoing barriers while simultaneously sustained by future-oriented hope.

Financial and service access barriers: families identified financial constraints and limited access to mental health services as major challenges. The cost of treatment, transportation, and daily needs placed significant strain on family resources, while difficulties in accessing services further complicated caregiving. "Sometimes we feel confused... we want to go for check-ups, but we don't always have the money, and the place is quite far" (P8). These barriers increased emotional pressure and uncertainty, highlighting how structural limitations can intensify the burden of caregiving.

Social pressure and stigma: caregivers also experienced social pressure in the form of stigma and negative perceptions from the community. Being judged or blamed for the adolescent's condition led some families to withdraw from social interactions. "My relatives said my child has become the talk of the neighborhood... they even said my child brings bad luck... it makes me reluctant to socialize and feel deeply hurt as a mother" (P11). This stigma not only affected social relationships but also contributed to emotional distress among caregivers.

Hopes for independence and social acceptance: despite these challenges, families expressed strong hopes for the adolescent's future. Caregivers wished for their children to become more independent, engage in meaningful activities, and be accepted by society. "I don't expect too much... I just hope my child can be independent and accepted by society" (P10). These hopes served as a source of motivation, enabling families to continue caregiving despite ongoing difficulties.

Discussion     

This study provides a deeper understanding of how family caregivers of adolescents with mental disorders navigate caregiving through emotional adaptation, social support, and the continuous negotiation of structural barriers and future-oriented hope. The findings indicate that family resilience is not a fixed condition, but an evolving process shaped by ongoing emotional, relational, and contextual experiences. This interpretation is consistent with previous research showing that resilience in mental health caregiving is multidimensional and influenced by family functioning, relational dynamics, and psychological resources.

The findings related to emotional experiences and adaptation indicate that caregiving is characterized by a fluctuating and non-linear emotional trajectory. Families initially experienced shock, confusion, and sadness, which continued to re-emerge throughout the caregiving process. This pattern is consistent with previous qualitative research demonstrating that emotional distress in caregiving does not diminish over time but becomes integrated into everyday life [19-21]. Rather than achieving complete emotional resolution, caregivers develop adaptive strategies that enable them to function within conditions of ongoing uncertainty. This indicates that emotional adaptation should not be understood as the elimination of distress, but rather as a continuous and evolving process of adjustment shaped by persistent caregiving demands and meaning-making processes [22-25]

Importantly, this study extends prior research by showing that emotional adaptation is closely linked to the meaning of parental responsibility. Caregivers interpreted their endurance as part of their role as parents, reinforcing their commitment despite emotional fatigue. Similar findings have been reported in studies where caregiving is sustained through moral obligation, identity, and long-term relational commitment [23,26-28]. These findings suggest that resilience is constructed not through the absence of distress, but through meaning-making processes embedded in family roles and responsibilities.

Social support emerged as a central component in sustaining family resilience. Evidence specific to adolescent and mental-health caregiving [2,15,17], together with broader comparative caregiver literature, indicates that support from immediate family members may reduce caregiving burden and enhance emotional stability [8,29]. In addition, mental-health-specific evidence [15,17,30] and broader comparative studies suggest that emotional and moral support from the social environment may reduce feelings of isolation and strengthen caregivers' coping capacity [8,30]. These findings emphasize the importance of relational networks as protective factors that sustain caregiving over time.

Within mental health care, collaborative relationships with healthcare providers are an important component of support for family caregivers [13,31]. Effective communication and caregiver-inclusive approaches may strengthen caregivers' confidence, self-efficacy, and engagement in care [32]. Nurses, in particular, often serve as an important point of contact for families by providing emotional support, psychoeducation, and practical guidance. Evidence from mental health and broader caregiving contexts suggests that emotional, informational, and instrumental support can contribute to better psychological well-being and coping among caregivers [13,31,33]. Strengthening nurse-family partnerships through family-centered approaches may therefore support caregivers' coping capacity and family resilience [31,32]. However, limited resources, restricted access to services, and discontinuity of care remain important barriers to effective family caregiving support [31].

Structural barriers, including limited access to mental health services and financial constraints, remain significant challenges for family caregivers, particularly in low-resource settings where institutional support is limited [34]. In such contexts, families often assume primary caregiving roles with minimal external assistance. Furthermore, evidence from caregivers of people with mental disorders [5,30,34], supported by comparative literature from other conditions, indicates that stigma is associated with caregiver burden, psychological distress, and poorer psychosocial well-being [35,36]. Stigma may also contribute to social withdrawal and emotional isolation, further exacerbating the challenges faced by caregivers [34].

Despite these challenges, families maintained strong hopes for the future, particularly regarding adolescents' independence and social acceptance. Hope emerged as a key psychological resource that sustains caregiving efforts over time. Empirical evidence indicates that hope is positively associated with psychological resilience among caregivers, enabling them to maintain adaptive functioning despite prolonged caregiving demands [37]. Evidence from mental-health caregiving [17,37], with broader family-resilience research used for comparison, suggests that hope may contribute to meaning-making and sustain caregivers' motivation and engagement in long-term care [38]. Rather than eliminating difficulties, hope enables families to endure ongoing challenges while maintaining a sense of purpose, reinforcing caregiving commitment over time.

Taken together, these findings suggest that family resilience should be understood as a dynamic and ongoing process in which emotional adaptation, social support, and hope interact within the context of persistent caregiving challenges. Studies focused on adolescent emotional disorders and family mental health [15,17,37], together with broader comparative resilience research, support understanding family resilience as an adaptive process shaped by interactions between stressors and available support systems [8,39]. Rather than representing the absence of vulnerability, resilience reflects the integration of both strengths and challenges within the caregiving experience. From a nursing perspective, these findings underscore the importance of family-centered approaches in mental health care. Evidence involving adolescents and caregivers in mental-health-related settings [12,13], supplemented by broader family intervention literature, suggests that healthcare professionals may support family resilience through emotional support, psychoeducation, and facilitation of social support systems [40]. These findings therefore support consideration of resilience-oriented and family-centered approaches in nursing practice, while their effectiveness should be evaluated in future intervention studies.

Limitations: this study has several limitations. First, it was conducted within a specific sociocultural context, which may limit the transferability of the findings to other settings. Second, participants were recruited from a limited geographical area, which may not reflect broader caregiving experiences. Third, the study primarily represents parents' perspectives without including adolescents or healthcare professionals. Finally, the cross-sectional design does not capture changes in caregiving experiences over time.

Implications: the findings suggest that family caregivers may benefit from being recognized as active partners in mental health care. From a nursing perspective, the findings suggest that nurses could consider providing emotional support, psychoeducation, and guidance to help family caregivers manage caregiving challenges. Family-centered approaches that address emotional burden, coping strategies, and communication may help support caregiver well-being and family resilience. In addition, strengthening community-based nursing support and improving access to and continuity of mental health services may contribute to more supportive caregiving experiences. Efforts to reduce stigma may also facilitate families' willingness to seek and sustain care, particularly through collaborative approaches involving nurses, communities, and healthcare systems. These implications should be considered in the context of the qualitative nature of this study and warrant further evaluation through intervention-based research.

Future directions: future research should explore the longitudinal development of family resilience and include multiple perspectives, such as adolescents, family members, and healthcare professionals, including nurses. Comparative studies across different contexts and intervention-based research, particularly nurse-led interventions, are also needed to strengthen evidence-based support for family caregivers.

Conclusion     

Family resilience emerged as a dynamic process through which family caregivers of adolescents with mental disorders adapt emotionally, draw on social support, navigate structural challenges, and sustain hope for their adolescents' future. These findings highlight the importance of understanding resilience as an evolving process shaped by emotional, relational, and contextual factors rather than as the absence of caregiving difficulties. Recognizing these dimensions may inform family-centered mental health support and future interventions for caregivers and adolescents.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Nor Afni Oktavia conducted the study, including conceptualization, data collection, analysis, and manuscript writing. Nicholas Pang Tze Ping contributed to supervision, critical review, and editing of the manuscript. Deena Clare Thomas contributed to interpretation of findings, critical review, and editing of the manuscript. All authors have read and approved the final version of this manuscript.

Table and figure     

Table 1: socio-demographic characteristics of the 21 family caregivers who participated in in-depth interviews in the qualitative study on family resilience, Banjarmasin, Indonesia, 2025 (N=21)

Figure 1: thematic structure illustrating the three overarching themes and subthemes identified from 21 in-depth interviews and three focus group discussions involving 18 additional family caregivers in Banjarmasin, Indonesia, 2025

References