The Patient as Parent: Family Matters

Today, a person diagnosed with mental illness is as likely as anyone to be a parent or plan on becoming one. Public perceptions and the mental health care system have not always kept up with this reality, however, and research shows that the impact of mental illness on the patient and family is rarely acknowledged in the clinical setting. Ignoring that aspect of a patient's life can undermine treatment.

Mental illness can have a significant impact on the family, resulting in higher divorce rates and problems with parent-child attachments. Depressed parents, for example, become less emotionally involved in their children's lives; and the children risk developing social, emotional and behavioral problems.

Psychiatrists who focus on codifying symptoms rather than looking at the central life tasks of a patient are missing an important opportunity, said William R. Beardslee, M.D., chair of the department of psychiatry and psychiatrist-in-chief at Children's Hospital in Boston. When a mother with depression says she needs help with her children, "That's where the manifestation of depression is for her. It interferes with her ability to take care of the kids. As a doctor, I need to attend to that."

A physician would never expect a patient with cancer or heart disease to get through the illness without additional support, Beardslee said in an interview with Psychiatric Times. "In the same way, we need to dignify the treatment of people with major mental illness." Psychiatrists need to ask about resources, supports and the people available to a patient in times of trouble.

Providers can help patients think prospectively about what they might need in the event of a crisis, such as who will take care of their children, said Joanne Nicholson, Ph.D., associate professor of psychiatry and family medicine at University of Massachusetts Medical School. Otherwise, patients may compromise their own treatment. If they have to go to the hospital but have no one to take care of their children, they will not go. Or, if they have to get up early, they may not take a medication that makes them feel lethargic.

"Oftentimes, our patients who are parents can appear to be noncompliant or resistant to our treatment suggestions, when in fact they're just trying to figure out how to make those suggestions work without compromising their role as parents," Nicholson told PT. The result is that parents with mental illness, like many parents, will prioritize their children's well-being in the short run and compromise their own well-being in the long run.

Studies that have examined record keeping and charts for people with mental illness have revealed that important information about the family is frequently left out, she said. It may be that the patient chooses not to give out that information, but more likely, the doctor is not asking the questions.

In June, the National Mental Health Association (NMHA) issued a series of fact sheets designed to address the tendency of service systems to view adults with mental illness in a vacuum. When children are not allowed to visit parents in inpatient facilities, or when community-based programs have no provision for child care, the parent's treatment progress is hindered.

Over the years, NMHA has received numerous calls from parents with mental illness and from adults who were raised by parents with mental illness, said Luanne Southern, M.S.W., the group's vice president of children's mental health services and prevention.

Often with parents, the calls concern divorce and other familial issues, Southern told PT. Frequently, parents find that their illness is being used in court to prove they are unfit parents. "There's such a tendency for society to assume that just because a parent is diagnosed with a mental illness, that automatically means they are unable or incapable of raising children."

Functioning as a Parent

Given the prevalence rates, Southern said, it is clear that many parents with mental illness are successfully raising their children. According to the U.S. Surgeon General's Report on Mental Health, one in five adults has a diagnosable mental disorder in the course of a year, 9% of adults experience some significant functional impairment as a result of their disorder, and 5.4% of adults are considered to have a serious mental illness.

Psychiatrists must remind themselves that the majority of adults with mental illness are parents and that having a diagnosis does not make a person an unfit parent, Nicholson said. Within each diagnostic category exists a wide range of parenting capacity, so that one woman with a diagnosis of bipolar disorder may function far better as a parent than does another.

More important than diagnosis alone, she explained, is gauging how the person functions on a day-to-day basis. Children often provide their parents with motivation and direction, and that is equally true for parents with mental illness. Even profoundly ill parents will rally themselves to raise their children.

Psychiatrists and health care professionals need to pay more attention to aligning treatment and supports with the basic impulse of parents to take care of their children, Beardslee said. In 20 years of research on the topic, he has found that people are powerfully motivated to be good parents. Along with treating the mental illness, psychiatrists need to help parents develop strategies for building strength and resiliency in their children. Education is a key component. The family needs to understand the illness and realize that no one is to blame for it.

Beardslee directs the Judge Baker Children's Center 10-Year Preventive Intervention Project, funded by the National Institute of Mental Health. The intervention project has studied 100 families in which one or both parents have experienced serious affective disorder and who were exposed to two forms of cognitive, psychoeducational, preventive interventions: either clinician-facilitated and/or lecture discussion group interventions. Beardslee and colleagues have found both interventions to be safe and feasible and are following the children to determine preventive effects over time.

One of the treatment outcomes must be a return to being a functional parent, Beardslee said. Rather than counting symptoms, psychiatrists need to focus on removing enough impairment so that patients can connect with their children.

Nicholson, director of the Program of Research on Parents with Mental Illness and their Families at University of Massachusetts Medical Center, agrees. A woman with severe depression, for example, needs to learn to explain to her child that her crying is part of a biologically based illness, not the result of something the child did.

Patient Parent

Psychiatrists in private practice may worry that they do not have the expertise or skills to address parenting issues with their patients, Nicholson said, so it is important to remember that parents have a great deal in common with one another. The challenges that a psychiatrist faces as a parent can help in relating to the problems that a patient experiences in terms of the day-to-day stress and challenges. The compromises to functioning brought on by mental illness are similar to the challenges faced by a parent with heart disease or diabetes. The illness raises a number of potential complications and concerns around hospitalization, medication and genetic transmission.

When a psychiatrist is treating an adult with children, Beardslee said, it is important to ask how the children are doing and to share information about the risks involved for them. A father with a severe anxiety disorder, for example, will need to know those risks so that he can identify problems early on and seek treatment for the child if they occur.

Depression and other mental illnesses are terribly misunderstood, Beardslee explained. Both the patient and family members tend to blame themselves for the illness, and doctors need to use an educational approach to confront this and other misconceptions. The illness must be placed outside the context of guilt and blame, he said, by explaining the biological nature of the illness and what the patient can do about it.

According to Southern, children of parents with mental illness should be provided support and information regarding the illness and what to expect from the parent during times when symptoms are more prevalent. They should be told that the illness is treatable, in order to dispel any fears they may have. Not all children of parents with mental illness will develop their own mental health problems, but they may be at risk for certain types of mental illness, including mood disorders, alcoholism and personality disorders. Beardslee pointed out that parents should be reminded that children can do well in spite of the parent's illness. Mental illness in a parent does convey an increased risk to children, but it is far from being a one-to-one correspondence. Genetic determinism is not inevitable, and a lot can be done to prevent it. "I think if anything, parents overemphasize the inevitability," he told PT.

Research by Beardslee and his colleagues in the 1980s, which formed the backbone of his prevention program, identified three characteristics of resilient youth:

• They are committed to accomplishing developmental tasks outside the home, such as doing well in school and taking part in sports and community activities.

• They are committed to relationships with siblings, friends, adults and parents.

• They understand that they are not to blame for their parent's illness(es) and are free to go on with their own lives.

Beardslee noted that the third characteristic is crucial for a child dealing with a parent's mental illness. It has three components: an understanding of the illness and its manifestations; a realistic sense by the child of what he or she can do for the parent; and a willingness to take action based on that understanding.

Knowing these characteristics allows the psychiatrist to teach parents with mental illness how to build resiliency in their children, he said. These strategies are especially important after a hospitalization, which disrupts the entire family's routine.

The System's Limits

The interventions that Beardslee's group developed in the '80s were designed to be compatible with managed care -- they were relatively short-term, manual-based programs. It has been very hard to get insurance companies to focus on mental illness prevention among family members, Beardslee explained. Health care costs continue to climb, and the orientation in the U.S. health care system is toward major interventions after trouble occurs.

Ultimately, the U.S. health care system needs to be restructured, Beardslee said. The Surgeon General's Report on Mental Health and subsequent reports on children and minorities identified problems inherent in the existing health care system, such as a lack of parity for mental health treatment and the lack of interventions that target an illness early on.

In the meantime, he said, more attention needs to be paid to anti-stigma and psychoeducational programs for families at risk.