Parents with serious and persistent mental Illness: issues in assessment and services.
However, first-person accounts and exploratory research have confirmed that parenting is very important to mothers who have a mental illness (Fox, 1999; Mowbray, Oyserman, & Ross, 1995; Sands, 1995). This issue affects social workers in child welfare and mental health settings, but little research has addressed assessment and development of parenting skills for adults with serious and persistent mental illness. Parenting is not typically considered a mental health issue, and parenting skills are typically assessed only when children are deemed at risk of out-of home placement rather than as part of a comprehensive psychosocial rehabilitation plan for the parent (Blanch, Nicholson, & Purcell, 1994). The social work profession should adopt a broader approach toward working with parents who have a serious and persistent mental illness. To accomplish this we need to develop specific assessment tools and interventions to improve these parents' competence to perform this important social role.
Focus on Parental Pathology
Literature on parents with mental illness has focused on parental pathology and its detrimental effects on children. Some researchers focus specifically on parents with serious and persistent mental illnesses, such as schizophrenia and major depression, whereas other studies include substance abuse and other moderate disorders, such as anxiety and dysthymia. A comprehensive literature review of major databases in the field, including Social Work Abstracts Plus and PsycINFO, found surprisingly few articles that address assessment and development of competent parenting in parents who have a serious mental illness. Most of the literature on assessment is related to child welfare, which is primarily concerned with determining when children should be removed from the home and when parental rights should be terminated. The mental health literature has little research on assessment of parental competence and what constitutes competent parenting by people with serious mental illness.
Historically, the mental health literature has focused on the negative aspects of parenting by people with serious mental illness. Most of the literature tends to be pathology focused and fails to address the strengths and capabilities of these parents. Researchers have understandably been concerned about the well-being of children who live with a mentally ill parent, but they have viewed the parent's mental disorder as an immutable problem that inevitably undermines the ability to be an effective parent. Most of the discussion is related to determining when children should be taken away from a parent and the possible damage to children who remain in these situations (Orvaschel, Walsh-Allis, & Ye, 1988; Stiffman, Jung, & Feldman, 1988; Thomas, Forehand, & Neighbors, 1995). In addition, the negative effect that separation and loss of the parental home may have on children who are removed from their biological parent has received insufficient attention.
Parents who have a serious and persistent mental illness are victimized twice. First, they experience a devastating neurobiological illness through no fault of their own. Then, they find themselves at risk of losing their children because they are viewed as permanently flawed and incapable of fulfilling one of society's most cherished roles (Fox, 1999). Research in child welfare has not addressed the psychosocial issues of mothers of at risk children and the effect of parenting on their mental health (Sands, 1995). Policies intended to promote a speedier resolution for children in out-of-home care may have an unintended discriminatory effect by singling out parents who have a diagnosed mental illness for "fast track" termination of their parental rights (Hollingsworth, 2000; Jacobsen & Miller, 1998). As a result, these parents face great barriers in trying to demonstrate their parental fitness without the necessary supports and services they need to become competent parents. Social workers have an important r ole in helping this disenfranchised group cope with the disability that accompanies their illness, including their ability to parent effectively.
Parents with Serious Mental Illness Overlooked
Parents with schizophrenia, major depression, bipolar disorder, and other serious and persistent mental illnesses have been overlooked for several reasons. The first reason is related to changes in the mental health service delivery system. Before deinstitutionalization many of these individuals resided in state hospitals and may have been less likely to marry or have children. An unforeseen consequence of the community mental health revolution has been an increase in women with a severe mental illness bearing and raising children (Bachrach, 1984; Burr, Falek, Strauss, & Brown, 1979; Nicholson, Geller, & Fisher, 1996). Research has found that women with serious mental illness marry and have children at the same rate as other women, but they tend to have very high separation and divorce rates (Nicholson, Nason, Calabresi, & Yando, 1999; Test & Berlin, 1981) and are at greater risk of losing custody of their children (Miller, 1992; Miller & Finnerty, 1996). Therefore, they are likely to have less support in the parenting role while struggling with these debilitating illnesses that affect their cognitive and emotional abilities.
Bias and stigma may have led the professional community to assume that parenting is a stressfu1 role that is not highly valued by these individuals. However, recent qualitative studies suggest that parenting is highly valued and is just as important as employment to mothers who have a serious mental illness (Mowbray et al., 1995; Sands, 1995). A compelling first person account details the agony and regret that one mother experienced as a result of losing her children because of her mental illness (Fox, 1999). Fox's story exemplifies the fate of many mothers whom mental health or child welfare professionals advised to give up their children instead of assisting them with the necessary supports and services that ould have helped the family remain intact. Fox's story is compelling because it conveys the sense of loss and regret experienced by both the parent nd her children.
Another reason these parents may have been overlooked is that they are caught in the gap between the child welfare and mental health systems. Their mental illness is viewed as an individual problem that is the responsibility of the local mental health system, whereas the safety and welfare of their children is the responsibility of the child welfare system. Who is responsible for the assessment and development of parenting competence is unclear and requires a well thought out plan for the integration and coordination of services (Blanch et al., 1994). Although parenting is a complex social skill that may be compromised by severe mental illness, it has not been a focus of community mental health programs (Nicholson & Blanch, 1994; Nicholson, Geller, Fisher, & Dion, 1993; Oyserman, Mowbray, & Zemencuk, 1994, Test & Berlin, 1981).
In child welfare, assessment methods used for recommending termination of parental rights do not typically distinguish between individuals with serious mental illness and those with other types of behavioral health problems (Azar, Lauretti, & Loding, 1998). Furthermore, many child welfare workers are inadequately prepared to deal with mental health issues. In a study of rural child welfare workers in Illinois, workers reported a need for in-depth training about mental illness in terms of services available, knowledge about mental illness, and assessment of mothers with a mental illness (Raske, 1997). The study found that child welfare workers perceived themselves ill equipped to deal with assessment and treatment of the mentally ill parents they serve. Therefore, they have to rely on mental health professionals for assessments and the development of services.
Because parenting is considered to be more of a child welfare concern than a mental health issue, the mental health literature has dealt with parents who have serious mental illness in a generic manner. Mental health researchers and clinicians typically ignore gender-related issues with regard to people with serious mental illness. Assessment and services in mental health address symptoms and functioning on a generic basis and fail to identify issues of concern to women, such as parenting (Test & Berlin, 1981). Even interventions that focus on psychosocial rehabilitation address work-related skills and employment but fail to address parenting skills (Nicholson & Blanch, 1994).
The delivery of mental health services may fail parents who have a severe mental illness because of an erroneous assumption that these individuals have the same characteristics and service needs as other consumers with serious mental illness. Two studies of case management clients in Massachusetts found that both mothers and fathers who have a mental illness are more likely than other clients to have a primary diagnosis of a major mood disorder and less likely to have a psychotic disorder (Nicholson et al., 1999; White, Nicholson, Fisher, & Geller, 1995). One of these studies found that mothers with serious mental illness who are the caretakers for their children demonstrated higher levels of functioning than other women with serious mental illness, even though they did not differ in their use of mental health services (White et al.). Another study found that women with schizophrenia who are mothers were more likely to have had better premorbid social adjustment, to have been married at some time, and to hav e had a later onset of symptoms than women with schizophrenia who were not mothers (Caton, Cournos, & Dominguez, 1999).
These studies suggest that parents with serious mental illness may have a clinical profile that is different from other mental health consumers. One of the few studies that looked at both fathers and mothers with a serious mental illness (Nicholson et al., 1999) found that these two groups were remarkably similar on demographic and clinical issues and could benefit from parent skills training and parent support services. Parents with serious mental illness represent a unique subset of mental health clients who, as a result of their illness and the demands of parenthood, need providers to give special attention to social support and treatment issues.
Issues in Assessment
Research on parents with serious mental illness is important in child welfare because of concerns about parental fitness and the question of when to terminate parental rights. Several states have adopted procedures for quicker termination of parental rights when a parent has a diagnosed mental disorder (Jacobsen & Miller, 1998). To single out parents with a mental illness is unfair. Caseworkers and judges face difficulties in defining who is mentally ill and how the disorder affects their parenting skills. Child welfare workers often must make difficult decisions about out-of-home placement and termination of parental rights with inadequate tools for assessing parental fitness and inadequate resources for promoting improved parenting skills with this population. Because mental health researchers have not done a good job addressing assessment of parental competence of clients with severe and persistent mental illnesses, the judicial system may see this as primarily a child welfare issue.
Some mental health professionals have advocated for behaviorally based functional assessments, but many professionals and judges continue to rely on personality tests and other assessment tools that may be inappropriate for this population in determining parenting competence (Azar et al., 1998; Azar, Benjet, Fuhrmann, & Cavailero, 1995; Jacobsen, Miller, & Kirkwood, 1997). Psychological instruments that are typically used for child welfare assessments have received little empirical testing regarding their efficacy for measuring parenting competence. Furthermore, judges and caseworkers tend to make decisions that reflect their own racial and ethnic background, and many judges apply a higher standard of parental competence that is more appropriate for divorce custody cases than for termination of parental rights (Azar & Benjet, 1994). As a result, many mentally ill parents risk loss of their parental rights on the basis of inadequate or inappropriate assessment methods and professional bias.
The heterogeneous nature of mental disorders and uncertainty about whether specific psychiatric diagnosis or severity of mental illness has the strongest effect on parenting ability further complicate the issue. Because mental illness can include a broad array of conditions, it is erroneous to assume that all mothers or fathers who have a diagnosed mental disorder are alike. Research on attachment disorganization has found potential effects of specific severe mental illnesses on parenting, but also supports the view that severity and chronicity of the mother's illness is more important than diagnosis. Studies showing that severely depressed mothers are less interactive with their children and less attentive to their children's needs suggest that major depression is a risk indicator for neglect and possible child psychopatholgy as a result of disturbed attachment relationships with the mother (Jacobsen & Miller, 1999; Lee & Gotlib, 1989). On the other hand, although parents with major depression have some cogn itive deficits and impairment in judgment, their cognitive deficits are not likely to be as severe as those of parents with an active psychotic or bipolar disorder. Parents with schizophrenia may have an impaired ability to read nonverbal cues or to engage in mutual social interchange and may present a greater risk of physical abuse as a result of hallucinations or delusions (Jacobsen & Miller, 1999; Seeman, 1996). Goodman and Brumley (1990) found that women with schizophrenia demonstrated a lower quality of parenting than depressed women who had no mental illness, but that parenting competence was more variable among depressed women. However, they also found that the mother's parenting practices and relational deficits, rather than her diagnosis, accounted for her children's intellectual and social competence. Similarly, it has been found that social competence in children is best predicted by multiple contextual risks rather than by psychiatric diagnosis (Seifer et al., 1996). In another study that differen tiated between seriously mentally ill mothers on the basis of diagnosis, differences in parenting attitudes were related to chronicity and severity of illness but not to diagnosis (Rogosch, Mowbray, & Bogat, 1992). This is consistent with other studies that have found that severity of illness influences parenting more than psychiatric diagnosis (Jacobsen & Miller, 1999).
Furthermore, the degree of functional impairment varies within all diagnostic groups of mentally ill individuals. Pioneering studies in psychiatric rehabilitation demonstrated that measures of functional and social skills are better predictors of community success than either psychiatric diagnosis or measures of symptoms (Anthony, Cohen, & Vitalo, 1978; Anthony & Jansen, 1984). Applying these principles to assessment of parenting competence, the focus needs to change from general assessment of parental psychopathology to more specific assessment of parenting skills and deficits along with a comprehensive assessment of the family's social support network and the home environment.
A few studies with this type of focus are reported in the literature. An in-depth small-scale study of mothers with chronic schizophrenia in Denmark (Grunbaum & Gammeltoft, 1993) supported the need for a precise assessment of parenting skills and measurement of the severity of the mother's illness and the child's vulnerability. Similarly, the study by Rogosch et al. (1992) suggested that a higher degree of severity and chronicity of psychiatric illness was correlated with poorer parenting attitudes among mothers with a severe mental illness. Because chronicity and severity were operationally defined as the number of psychiatric hospitalizations in the past three years, the degree of functional impairment and severity of symptoms was implied rather than measured directly. Despite this limitation, the results of the path analyses by Rogosch and colleagues offer valuable insights for assessment, because they identified two independent pathways that determine parenting style in mothers with severe mental illness. The first pathway indicated that frequent relapse--the measure of chronicity and severity of illness--had an independent and significant negative effect on parenting attitudes. The second pathway, which included childhood relational experiences and current supportive relationships, predicted more adaptive parenting attitudes and was consistent with factors that influence positive parenting in mothers who do not have a severe mental illness.
A more sophisticated approach to assessment is needed that focuses on specific behavioral, cognitive, and social skills of mentally ill parents. Assessments should be oriented toward determining functional impairments and competencies rather than general psychological assessments and diagnosis, with an emphasis on competent parenting skills rather than optimal parenting abilities. It has been argued that one way to counter unintended bias by judges, caseworkers, and mental health professionals is to adopt assessment procedures based on cognitive--behavioral models of parenting that assess specific parenting knowledge and skills (Azar & Benjet, 1994; Azar et al., 1998). Assessments also should include observation of the parent--child interaction in multiple contexts, including an evaluation in the home (Jacobsen et al., 1997).
Assessments that include multiple, interdisciplinary sources of information in multiple contexts obtain a holistic picture of the family and home environment. This is particularly important in homes with a parent who has a serious mental illness, because child well-being is strongly influenced by who is around to care for the children when the parent becomes acutely ill or is hospitalized. A major failing of our current approach is to assume that a mentally ill parent is inherently flawed and incurable or is cured or fully recovered because his or her symptoms are stabilized. A more balanced understanding of the nature of serious and persistent mental illnesses is needed. Such an approach allows for recognition of levels of recovery that may be conducive to psychoeducation and rehabilitation interventions. It also recognizes the cyclical nature of these disorders, which indicate that at times the ill parent may need more intensive treatment and may require various levels and types of social support.
Therefore, a comprehensive assessment would include severity of illness, assessment of strengths and competencies, in-home and out-of-home observations, and the level of social support available to and needed by the whole family. Such a comprehensive approach to the assessment of parenting competence would help identify specific skills to be addressed in a rehabilitation or treatment plan. It also would address the social, emotional, and economic support needed for both the parents and their children. This assessment process would focus more on what needs to be done to promote parenting competence and a safe home environment and contribute to a more informed and humane process for determining when to remove children from the home and when to terminate parental rights.
Parenting classes for the general public often are conducted as part of wellness programs in hospitals, clinics, and a variety of community agencies, including mental health agencies. However, these programs are seldom designed for parents with serious mental illness. Child welfare agencies or family court judges may order mentally ill parents to attend these classes, but without adequate knowledge about whether these resources are appropriate for the parents' degree of psychiatric illness or cognitive impairment. An unintentional stigmatization may be attached to these programs because of a lack of fit between the mentally ill parents and other members of the group. As a result, parents with serious mental illness may drop out or fail to receive the desired benefit from these programs. When these parents do participate in general parenting classes, the didactic method of instruction combined with the severity of their illness may impede their ability to apply the lessons to their own situations.
Special parenting classes and programs designed for individuals with serious mental illness are rare and typically exist as pilot programs that are limited in size or to one location (Cohler, Stott, & Musick, 1996; Oyserman et al., 1994). The Denver Mothers' and Children's Project is an early example of a program designed to teach parenting skills to mothers with schizophrenia (Waldo, Roath, Levine, & Freedman, 1987). The weekly program focused on teaching parenting skills to the mothers and monitored the developmental progress of their preschool children. The mothers continued to receive treatment for their mental illness from either a community mental health clinic or a private therapist, thus this program was not an integrated treatment program for these mothers and their children.
A more comprehensive approach to teaching parenting skills for mothers with a psychotic disorder was developed in Great Britain as Project CHILD (Rubovits, 1996). This program focuses on teaching the mothers appropriate social and relationship skills with their children and includes home visits, specialized parenting skills training, and social activities. Seeman and Cohen (1998) described a program in Toronto in which inpatient, outpatient, and outreach services were combined, providing services and assessment through one specialized psychiatric clinic. Other programs in the United Kingdom and Australia use hospital-based mother-baby units to support the mother in time of psychiatric instability and to teach the mother parenting skills, but these programs have not gained widespread acceptance in the United States (Oyserman et al., 1994). Some of these programs are limited to the hospital setting, whereas others provide in-home visits. Oyserman and colleagues found that these programs tended to focus primaril y on the mothers' pathology with little attention to social and environmental factors. As a result, they have advocated for psychosocial rehabilitation programs that incorporate a broader approach to assessment and services for mothers with serious mental illness and their children.
Psychiatric rehabilitation programs have emphasized psychosocial interventions that improve community functioning and enhance work skills and other socially valued roles for individuals with serious mental illness. However, most of these rehabilitation programs have failed to address parenting skills (Nicholson & Blanch, 1994). The Mothers' Project, operated by Thresholds in Chicago, combines a psychosocial program, a case management service for the mother and child, and a therapeutic nursery for infants and children up to age five (Zeitz, 1995). Family support services are offered to fathers, husbands, and parents of the participating mother. The program recognizes that these other family members may be important social supports for the mother, especially during times of psychiatric instability. However, as in Project CHILD, these services end when the child enters school, at which time the mother and child return to the conventional mental health and child welfare system.
It is not clear whether psychiatric rehabilitation programs offer a significant advantage over other intervention methods. For example, a comparison study was conducted of the Thresholds' Mothers' Program and the Home Care Program, a similar program for mentally ill mothers in Chicago in which training was conducted during home visits. This study found that participants in both programs showed significant improvement in parenting skills and cognitive functioning, and that mothers in the Thresholds program had a lower rate of rehospitalization. However, there were no significant differences in observed parent-child outcomes between the two interventions (Cohler et al., 1996; Oyserman et al., 1994). Although mentally ill parents can benefit from programs designed for them, the components that contribute to improvement in parenting skills and parental mental health have not been clearly identified. Perhaps a variety of approaches, rather than one intervention model, is effective. More work is needed in the devel opment and empirical evaluation of these interventions.
Many professionals working with parents who have serious mental illnesses focus on the pathology of the parent. Discussions of when to expedite termination of a mother's parental rights often fail to adequately address what is needed to assist the mentally ill mother and family members coping with parental responsibilities. Much of the practice and research literature also overlooks the importance of parenting to these individuals, which may serve as a strong incentive to develop skills that enable them to become better parents and to manage their mental illness better.
Researchers who have studied the issue of parents with serious mental illness have focused on women and their experiences as mothers who must deal not only with the demands of parenting but also with the disability associated with their mental illness. These women worry about losing custody of their children, and many also struggle with poverty (Zemencuk, Rogosch, & Mowbray, 1995). Despite this, women with serious mental illness view parenting as a highly cherished role and deserve our support and expertise. This support does not need to come at the expense of the children living in a home with a mentally ill parent, but should enhance the lives of all members of the family.
Most of the literature focuses almost exclusively on mothers. Very little literature on fathers has been published, and virtually none that examines parents as a group. In conducting the literature review for this topic, only one article was found that specifically addresses fathers who have a serious mental illness. This may be in part because of a recognition that women have traditionally assumed primary responsibility for child rearing and because many seriously mentally ill parents are single mothers. The focus on mothers also may reflect the prevailing conceptualization of this issue as an individual problem with a focus on pathology and deficits. This is in contrast to the broader literature on parenthood, which views this major social role as a shared responsibility among mothers, fathers, and the larger community. Such a narrow view of this issue is in conflict with the person-in-environment emphasis in social work and limits our ability to develop effective programs and research strategies.
As a profession, social work is in a unique position to help bridge the gap among the various fields of research and practice on parenting and serious mental illness. Many social work researchers and theorists in the human development arena have helped build the current body of research on parenting roles and skills. Many counseling and education classes that focus on parenting are led by social workers in health and mental health settings. Finally, social work has been one of the primary professions in the development of community mental health and psychosocial rehabilitation programs.
Original manuscript received November 15, 1999
Final revision received June 19, 2000
Accepted June 26, 2000
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Barry J. Ackerson, PhD, is associate dean, School of Social Work, University of Illinois at Urbana-Champaign, 1207 West Oregon Street, Urbana, IL 61801; e-mail: firstname.lastname@example.org.
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|Author:||Ackerson, Barry J.|
|Date:||Apr 1, 2003|
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