The Göpfert, Cowling, and Seeman model of assessment for grandparent care when a parent has a mental illness.
The family is a complex network of roles and tasks and responsibilities. The parenting role is central, and the children’s tasks– that is, to grow up and develop – depend on the parents’ ability to facilitate the process by nourishing children emotionally and physically, keeping them safe, and transmitting values that enable them to mature within their appropriate culture, and eventually to develop into responsible adults. Another important family domain is the spouse/partner relationship – in this case, the grandparents’ relationship with each other, but that has to be secondary to the child/parent focus. A key assumption underpinning a family assessment is that adults are motivated to fulfill their parenting role (although illness/personality problems may put obstacles in the way) in the best interests of the child. An initial focus on family interactions will then pave the way to a subsequent identification of the community supports that the family needs (Wu et al., 2010).
Maintenance of a long-term perspective is important, especially in the case of grandparent care, since unresolvable conflicts may result in frequent changes of care and family relationship patterns. A longer-term view must also consider the increasing health problems grandparents may experience, and the changing needs of children as they mature.
The literature has focused on interventions with individual family members, predominantly either the grandparent or the grandchild (Kelley et al., 2010; Montoro-Rodriguez et al., 2012), since parents in these cases are the most difficult to engage, but they may be the most crucial. As in the model, the needs of individual family members are probably best met by addressing the family as a whole and considering each individual family member’s requirements, while maintaining a focus on the needs of the children. As yet, no outcome studies show that this method is most effective, although, as a theoretical model, it has found favor in a number of contexts and has become part of policy in many jurisdictions (Carr, 2014).
Emerging evidence suggests that some family interactions, labeled “family social capital,” promote social adjustment in children and are essential to a family’s ability to access community support systems, or “community social capital” (Wu et al., 2010). The family is, thus, crucial to mental health, and to resource access. Family social capital refers to bonds between parents or grandparents and children and is represented by time and attention the adult carer spends with the child. Its components are family structure, parenting style, and family interactions (Wu et al., 2010). Building on the theory of family social capital, this chapter recommends a family-focused way of working and intervening with families where the grandparent is the primary care provider for the children. Consequently, service providers involved with such a family should consider the family as a whole irrespective of their particular service remit, and should rightfully be able to expect others involved with any aspect of the family to be responsive to their attempts to do so. Skills in assessing whole family needs are critical in this work (see Chapter 7).
Case study
The following case study illustrates opportunities for assessment and intervention when grandparents raise their grandchildren. It is based on a composite of families seen at a psychosis clinic; names and identifying information have been removed. Our comments follow each segment of the family narrative.
Mary and Paul married in their early twenties and had an only child, Sue. In her late teens, after a bout of fever and a visit to her physician for antibiotics, Sue became convinced that the doctor had poisoned her. When the conviction persisted, she was diagnosed with schizophrenia. Mary and Paul were devastated, but were given no support to learn about this diagnosis or its consequences for Sue, and for the future of the family. The hospital focus was on Sue, and, as she was an adult, Mary and Paul were not informed about her treatment.
Sue’s diagnosis was an opportune time for family support. Acknowledgement of the loss each person experienced, provision of information about the diagnosis, and Paul and Mary’s responsibilities as parents, and Sue’s own responsibilities, may have assisted in reducing conflict, thus providing an opportunity for a new start to their relationship.
When Sue returned from hospital, she refused to stay on the recommended medicine and continued to believe that she had been poisoned. A family counselor was assigned to the family but mostly took Sue’s side in family disagreements. Sue attended a number of therapy groups where she concentrated on dancing and meeting men. Mary and Paul worried about her behavior but tended to be lenient because she was ill.
Mary and Paul remained confused about their responsibilities and how to manage them. Sue’s return home intensified this, as did the family counselor’s intervention, because the sole focus was on Sue’s needs and perceptions or feelings. An alternative focus could have been clarification of Sue’s personal goals as part of her recovery plan. This might have enabled more family participation in decision-making, less avoidance of confrontation, and better resolution of conflict.
The family counselor did not address interpersonal safety or contraception, even though Sue was open about how much she wished she could have a baby.
The counselor could have explored with Sue what it meant to her to be a mother, and what it meant to her if this wish were not fulfilled, as well as discussing the practical aspects of being a parent.
At age 24, Sue became pregnant. Mary thought Sue should terminate the pregnancy. Paul thought she should give the baby up for adoption. Sue decided to keep the baby, and named her Sandra. Against Sue’s will, Mary and Paul applied for and were granted legal custody of Sandra. They joined a support group for grandparent caregivers, received support, and discussed their concerns with a counselor.
However there was no coordination between the services working with Sue, and neither Mary and Paul and the service providers did not communicate with one another.
Becoming a mother might have been Sue’s way of resolving her dependency dilemmas in her family of origin but lack of communication among family members and service providers led to an increase in conflict, leading, in turn, to legal involvement.
Over time, Mary and Paul became parents to Sandra. Sue periodically moved away from home, either to be hospitalized or to live with a new boyfriend.
Four years later, Sue had another daughter, Selene. Sue and her parents attended psychoeducation sessions together and learned to better understand Sue’s illness.
Paul and Mary, approaching their sixties, gained legal custody of Selene, this time with Sue’s agreement, and with a plan for her continued participation in parenting. Sue began taking her medicine by depot injection. She became less labile and much more involved and interested in looking after her daughters.
This illustrates how a second child can provide a second chance to the parent, especially if services provide appropriate support.
Paul and Mary developed medical problems, and so they were less able to physically look after the children. Their employment routines were disrupted, affecting their finances. They lost touch with close friends, and their relationship deteriorated. A marriage therapist helped them, but did not communicate with Sue’s service providers.
Sue had behavioral problems that contributed to her parents’ burden, and they asked her psychiatrist to provide behavior therapy. This helped Sue adapt her sleeping pattern to the children’s requirements, and she became increasingly reliable as a parent. Mary and Paul arranged for the children to attend a group for young carers.
This shows that grandparents can learn to become assertive and effective in their demands for appropriate intervention.
Sue then met and moved in with a new boyfriend, John. Sandra and Selene were jealous of John’s children and the time their mother spent with them. Sue asked her daughters to come for sleepovers, but they refused.
Appropriate intervention could have helped to resolve the children’s understandable reactions to the intrusion of a second family.
Sue eventually moved back to her parents, but she stopped her depot injections and her health deteriorated. Sue’s many hospital admissions and changing boyfriends led her daughters to believe they could not depend on their mother. At the same time, their grandparents were aging, and Paul was hospitalized with a stroke. Both Sandra and Selene had difficulty with schoolwork.
Sue started to think that her girls didn’t need her any more and expressed her wishes for another baby. This illustrates how rebellion against loss of the parental role and a need to be cared for can lead to the wish for another baby. Sue’s daughter, Selene, aged 14, fulfilled her mother’s wish and became pregnant. Mary and Paul were in their eighties and had a fourth daughter to raise.
This case illustrates the strengths and capabilities, and limitations and needs, of a family and its individual members. Each should have been considered in a family-focused assessment, with support provided for each person as well as for the whole family. A mostly individual service focus, lack of communication between Mary and Paul, and lack of coordination among different services led to an unnecessarily poor outcome.
Summary
This chapter poses the question, how do children of parents with mental illness raised by their grandparents fare as adults? This central question raises many others relating to the family and to each generation – for example, experiences of separation and their long-term effects on grandparents, parents, and children. A priority in this field is the development of research evidence concerning the impact of the care of children of parents with mental illness by their grandparents on each of these three generations.
Many grandparents are cast with little preparation into the role of primary caregivers to the children of their children at a time of life when their own health may be suffering. Overall, the rate of grandparents acting as primary caregivers is increasing while their access to public assistance and support remains limited. We have described some of the positive and negative potential impacts on grandparents, parents, and children. Problems may emerge for all three generations, and, currently, there is little research to guide best practice. We propose a standard procedure whereby all grandparent-headed families be assessed and formulated as whole families first, with individual assessments and intervention plans embedded within this family formulation. This will require training for all mental health professionals in the art of family formulation. A formal family assessment might not always be possible, and a tentative and incomplete family formulation might have to do in some circumstances, but – as demonstrated in the case study – a purely individual focus as the starting point of service provision often leads to increased fragmentation and less than optimal outcomes.
Related posts:
Thinking about children of parents with mental illnesses as a form of intergenerational dialog and practice
Mothers with eating disorders and their children
Helping children understand their parent’s mental illness
E-learning professional development resources for families where a parent has a mental illness
Preventing unnecessary loss of child custody
Parental psychiatric disorder: translating The Family Model into practice change
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