Parents With Mental Illness Face Daunting Challenges

People with serious and persistent mental illness often face unique issues surrounding their role as parents, issues that should be addressed during psychiatric treatment, according to a panel of Baltimore-area psychiatrists who spoke at APA's Institute on Psychiatric Services in Atlanta in October.

Some of these issues include losing custody due to repeated hospitalizations, being unable to care for a child due to debilitating psychiatric symptoms, or needing the support of family members to raise a child.

“In an opening dialogue with patients, we tend not to ask questions about parenting,” noted Ann Hackman, M.D., medical director of the Programs for Assertive Community Treatment (PACT) team at the University of Maryland Medical System in Baltimore.

Although questions such as “Have you ever had children?” often come up during the initial assessment, she said, “we don't necessarily get back to them.” This is the case with both men and women patients, she added.

Giving patients the opportunity to talk about their feelings about parenting is important, she noted.

Clinicians should determine the level of the patient's involvement with his or her child and address whether problems such as psychiatric symptoms, homelessness, or substance use interfere with the parent-child relationship.

One of Hackman's patients told her she would have loved to have children, but began experiencing symptoms of serious mental illness at age 17 and was never able to maintain a relationship with a significant other. For that reason, the woman never felt she could have children. “That's a loss that merits discussion,” Hackman said.

Hackman sometimes hears from patients that medication side effects or psychiatric symptoms “impact dramatically on the ability to be the parent they would have liked to be,” she said.

Psychiatrists can help patients who are parents in other ways as well, such as helping them manage visitation of their children or get involved in parenting classes and peer support groups, such as a women's support group at the University of Maryland Medical System.

In the group, Hackman noted, women may discuss “how to strengthen the relationships they have with their children or how they were able to successfully raise their children despite repeated hospitalizations.”

In addition, she said, some support-group members “talk for the first time about the trauma of having their children taken away from them.”

Theodora Balis, M.D., a member of the PACT team, said societal stigma“ may have led many to believe that parenting is not highly valued by people with mental illness” and that “women with serious mental illness have multiple partners and above-average fertility rates,” which all have been disproved by scientific literature.

The proportion of women with serious mental illness who lose custody of their children ranges from 30 percent to 60 percent, depending on the study, Balis said.

She quoted sociologist Erving Goffman, Ph.D., who in 1961 wrote that“ patients with serious mental illness are victimized twice as they first experience a devastating neurobiological illness through no fault of their own and then find themselves at risk for other losses including losing their children.... They are viewed as permanently flawed and incapable of fulfilling one of society's most cherished roles.”

Balis noted that many psychiatric patients lose custody of their children during hospitalization. Fear of losing custody of children for this reason may keep many people with mental illness from seeking treatment, she said.

Clinicians need to be educated about the likelihood that women with serious mental illness either have or may have children, and if they do have children,“ parenting should be an important part of treatment planning and case management services,” she said.

When people with serious mental illness become parents, it may become necessary for members of their extended families to step in and take over many of the roles the parent would normally assume, said Curtis Adams, M.D., an assistant professor of psychiatry at the University of Maryland and a member of the PACT team.

Parents or siblings of the person with mental illness may assume the role of guidance counselor or confidante of the relative's child because the ill relative may be unable to do so.

The family member may also need to educate the child about his or her parent's mental illness and even serve as interpreter for the parent.

In his work with family members of people with serious mental illness, Adams noted that “often a family is a tyranny ruled by its sickest member.”

It is easy for family members to lose themselves in the responsibilities of caring for the sick relative and his or her children, he noted.

In some families, it is a couple who assumes these responsibilities and lose their lives together in the process of dealing with the relative's illness, Adams said. To help them regain their lives, he said, “If they haven't been on a date recently, I prescribe a date, and the next time I see them, I ask them where they went.”

“It is important that the relative's illness not dominate their lives, and this can easily happen, especially where parenting issues are concerned,” he added. ▪