Prevalence of custody loss in mothers with psychosis

Approximately 50% of mothers with serious mental illness lose custody of their children at some time in the child’s early life, the percentage varying by jurisdiction. A report from Canada indicates that 84% of parents in treatment for schizophrenia were not living with their children at the time of the study (Gewurtz et al., 2004). This figure includes both mothers and fathers, although mothers usually make up more than 60% of parents in the context of severe mental illness. In a study of 322 such women, Hollingsworth (2004) found that 26% had lost custody at some point in the child’s life. A survey of mothers in psychiatric rehabilitation services (Dipple et al., 2002) reported that 68% had been permanently separated from at least one child. The actual prevalence of custody loss varies widely not only by jurisdiction but also by income level of the community studied, by diagnosis, and by other interrelated factors. The hope is that, as the stigma of mental illness lessens and therapeutic interventions improve, the number of mother–child separations will progressively diminish.

The impact of diagnosis on custody loss

Mothers with severe mental illness (SMI) believe that the public equates the diagnosis of SMI with parental incompetence or, worse, with parental neglect or violence (Savidou et al., 2003). Ackerson (2003) has memorably stated that parents diagnosed with psychosis are victimized twice; first, by psychotic illness, and then by the “protective” removal of their children from the home.

The impact of custody loss on mothers

Removing a child from a mother’s care causes her incalculable grief and distress although the mother with SMI may be too ill at the time of child apprehension to fully appreciate what is happening. Sands and colleagues (2004) have reported that mothers with SMI whose children are apprehended are often bewildered about what steps they can take to reverse the decision. Diaz-Caneja and Johnson (2004), in their qualitative study of twenty-two mothers with schizophrenia, concluded that fear of losing child custody or access to children is so central to the concerns of severely mentally ill women that they never discuss their parenting difficulties with healthcare providers. Unfortunately, never discussing difficulties makes their resolution unlikely.

Postpartum vulnerability to custody loss

The postpartum period is a particularly vulnerable time for women at risk of losing custody. Psychotic symptoms may emerge for the first time during this period, and, for mothers with a prior history of mental illness, the risk of relapse is high (Matevosyan, 2011; Vigod and Ross, 2010), bringing with it a very real threat of protective removal of children. Neonates are the most vulnerable members of society, and child-protection legislation is therefore biased, as it needs to be, towards their immediate needs rather than to the needs of the also very vulnerable mother, or, for that matter, to the long-term needs of the developing infant or child. In order to meet the demands of competent infant care and to keep families together whenever possible, young mothers with severe postpartum psychiatric illness constitute a population most particularly in need of support and advocacy (Lagan et al., 2009). Resources need to be directed to appropriate intervention during this critical period.

Terminating parental rights

The central issue involved in cessation of parental rights is the child’s safety. When an environment is unsafe, the child must be removed until the situation substantially improves (Brockington et al., 2011; Monds-Watson et al., 2010). For small children, the safety of the environment is generally judged on the presence or absence of abuse and neglect. The parent must be able to provide basic care (shelter, nutrition, hygiene, clothing, and medical care) and security (protection from dangers, including dangerous people whether violent or psychologically abusive). As the child grows older, other domains of the parental environment take on additional significance. Brockington et al. (2011) categorize these as the parent’s ability to provide:

Assessing competent parenting requires skill and experience. While gross neglect and abuse may be visible, the more subtle qualities of parenting are much harder to evaluate. Parent competency instruments are imperfect – they tend to focus on deficits rather than on strengths, and they are subject to cultural biases, since parental norms differ among cultures and are subject to fluctuation over time (see Chapter 7 of this book; Hogan, 2003; Seeman, 2008).

Overrepresentation of psychiatric patients in parental termination hearings

Besides parental competence per se, associated conditions, such as physical and mental health, the effects of drugs (both street drugs and therapeutic drugs), lifestyle, hospitalization history, quality and permanence of living arrangements, employment record, availability of social support, and socioeconomic status, enter into decision-making about custody. These variables overlap with mental illness, and, as a result, parents with psychiatric diagnoses are overrepresented in parental termination proceedings. In an Australian study, parental psychiatric illness was the most prevalent condition at such court hearings (Llewellyn et al., 2003). Partnership status is also important – single women (and this describes the majority of women with a diagnosis of schizophrenia) are more likely to lose custody than are their married peers (Strega et al., 2008). Social integration within a network of family, friends, and community members, often lacking in women with schizophrenia, is crucial to good parenting (Hollingsworth, 2004). The more robust a social network, the less likely it is for children to be apprehended by child-protection services. Perhaps most important are the diagnoses of schizophrenia and substance abuse (Howard et al., 2001), especially the latter, which can lead to child neglect and which, in addition, is considered a moral flaw that the mother is unwilling to change (Jones et al., 2008; Lewin and Abdrbo, 2009). She is, therefore, blamed for deliberately harming her children. Altogether, there are many interacting factors that determine out-of-home placements. Mothers suffering from mental illness find it very hard to attend, on their own, to all the factors that can disqualify them from being seen as adequate parents.

Preventing unnecessary custody loss

There are several ways, however, in which mothers with SMI can reduce the risk of their children being taken from them. It is the responsibility of the mental health team to provide mothers with the necessary information and to help to train them for the very important role of “good enough” (Winnicott, 1965) parent (Kundra and Alexander, 2009).

Maintaining mental health

A cornerstone of good parenting is to maintain one’s own health. This includes proper diet, a healthy sleep schedule, an exercise program, regular physician and mental health visits, and adherence to a prescribed regimen of medication. While some women with SMI do not want to be seen as needing medication for fear that this will label them as unwell, and others do not want to take medication because side effects make it difficult to care for their children (Seeman, 2012a, 2012b), most, when questioned on the topic of medication, understand that custody can be lost if prescribed treatment is not adhered to (Busch and Redlich, 2007).

When women refuse treatment, the intense desire to retain custody of children can be used as a form of leverage, an effective strategy (Busch and Redlich, 2007; Monahan and Redlich, 2005; Nicholson, 2005), but controversial in that it constitutes a form of blackmail.

As symptoms of psychosis decline with effective treatment, parenting stress is reduced and the quality of parenting inevitably improves (Kahng et al., 2008), although addressing symptoms alone is never sufficient (Wan et al., 2008). For some women, it is not only insufficient, but essentially ineffective. Even then, it is wise to not give up on psychiatry; patient cooperation with intervention demonstrates a woman’s seriousness about looking after her health and taking appropriate responsibility for her recovery.

Self-monitoring for triggers and warning signs

Warding off the return of symptoms and the probability of hospital admission is important in the context of parenting, which means that self-monitoring and anticipatory planning need to be taught. For instance, mothers can be shown how to maintain a written list of personal relapse triggers and early warning signs of the return of illness (sleeplessness, lapsed hygiene, increased suspiciousness, and so on) and educated about the effects of medications. The concept of titrating dose to stress level is an important one; the range of safe daily dosages needs to be discussed. Documentation of what has worked in previous episodes and what has averted relapse following a crisis is another useful exercise. Most of all, mothers need a plan and ready access to help in the event of a crisis. Evidence of self-monitoring and planning ahead demonstrates that the woman in question recognizes that she suffers from a potentially relapsing illness and acts accordingly (Seeman, 2012a).

Developing a crisis plan

Should hospitalization become necessary, mothers must be prepared. Several crisis plan templates are available electronically for parents with mental illness (Reupert et al., 2008) but, to be effective, these plans need to be individualized (Farrelly et al., 2013). It is best for all family members and all care providers to be involved in developing the crisis plan. The aim is to negotiate what needs to occur in an emergency and to clarify the responsibility of each member of the support network. Older children may be the first to notice early parental symptoms, and they need to know where to access emergency help.

The phone numbers and addresses of surrogate caregivers must be made available to children and also to the mental health team. Thought should be given to the establishment of back-up caregivers in case of the unavailability of first choices. The plan should be written down, shared, and periodically updated because names and details change with time. The plan should include critical information about the children’s needs in case of maternal absence: contact information of their doctor, dentist, and teachers; a list of allergies as well as food and activity preferences; disposition of pets; favorite toys; bedtime routines; and their medical and psychological history. Reupert and colleagues (2008) report that it typically takes 6–12 months to develop a comprehensive crisis plan because all the necessary interagency meetings take that long to organize. Again, a written plan indicates to child-protection workers that mothers are fully aware of their parental responsibilities.

Taking advantage of parenting resources

Depending on the community, parenting skills classes, parenting mutual aid or support groups, parent coaches, parenting warm lines, home visiting, and respite services may all be available to mothers with psychosis (Krumm et al., 2013; Phelan et al., 2013; Seeman, 2010; Zeanah et al., 2006).

An online parenting course has even been developed in the Netherlands especially for parents with mental illness (van der Zanden et al., 2010). In addition, the mental health team should be able to point mothers to specialized substance abuse-prevention programs (Niccols, 2012) and other appropriate resources as needed (Reupert and Maybery, 2007; 2011; Reupert et al., 2012).

Attendance at parental skills training sessions is evidence of a mother’s desire to be the best possible parent.

Documenting household and child-care routines

When asked to give evidence of good parenting, to defend themselves against the charge of incompetence, many women with SMI do not know what to say. They need help with this. Keeping a diary, documenting the day-to-day manner in which they address their child’s instrumental and emotional problems, how they help their child resolve conflicts, how they set limits, and how they help to socialize their child will give them data for their defense. They need to build a record detailing their parenting strengths and the quality of the bonds that exist with their children. Writing is a difficult task that takes time and patience, but it can provide stronger evidence than spoken words.

Navigating the legal system

Mothers with severe mental illness need to acquaint themselves with the mandated child abuse reporting laws of their jurisdiction. They need to connect with family law experts who understand mental illness and the family court system, and who are prepared to act as strong advocates. Policies intended to promote a speedy resolution for children in out-of-home care may unintentionally discriminate against parents with mental illness because they fast-track the termination of parental rights, allowing only a brief time period for parents to meet the goals set by child-protection agencies. Attorneys and care providers need to help mothers achieve these goals as quickly as possible by ensuring rapid access to the necessary supports and services. Collaboration between child-protection agencies and lawyers who represent parents in custody and termination proceedings is critical. It is not an easy collaboration, however, because child welfare professionals and court professionals come from two very different cultures. Health professionals are often uncomfortable in the legal adversarial system (Han et al., 2007) while lawyers and judges may lack a good understanding of mental health realities.

Recommendations for policymakers

Early intervention services, adult mental health services, and child-protection services need to cooperate rather than, as it sometimes seems, compete with one another (Darlington et al., 2005). Fundamental is a philosophy and care system that addresses the needs of the whole family. Wraparound services for families affected by serious mental illness are now a reality in several parts of the world (Kessler and Ackerson, 2005).

The term, “wraparound”, is increasingly being used to describe a family-driven, strengths-based approach that uses an array of both formal services and natural supports (Winters and Metz, 2009). Another way of defining such services is by referring to a “system of care.” A system of care is a network of structures and relationships held together by shared values and operating across administrative and funding jurisdictions (Bruns and Walker, 2010; Hodges et al., 2010). A family-driven system of care is based on the needs of children, parents, and extended family. It supports choice, ongoing evaluation, and accountability, and promotes partnerships between families and professionals, collaboration between multiple agencies and service sectors, and individualized services that are sensitive to cultural differences. The cultural sensitivity of a service refers to the ability of its staff to understand, value, and incorporate the perspective of all families regardless of background or tradition.

In such a system, there is a single point of entry for the many services that are provided. Among these may be early identification and prevention strategies; attention to reproductive and child health; substance abuse counseling; case management; liaison with schools and the legal system; financial support; crisis management; housing and transportation aid; vocational help; spiritual, cultural, and recreational guidance; and respite care. Ideally, the services are open-ended and aware of the stigma often associated with mental illness. Cook and Steigman (2000) advocate supports specifically designed for keeping families together. They identify the following as important aspects of a system of care for families where a parent suffers from a mental illness: assessment of parenting strengths and needs, birth control counseling, pregnancy decision-making support, trauma and abuse counseling, peer support, parent mentoring, self-help, support groups for children, and medication management. Specific counseling on benefits and entitlements is also critical for low-income mothers, some of whom may be intermittently homeless and require housing support (Weinreb et al., 2007). Administrative policies, training opportunities for service providers, and hard work on the part of mothers themselves are all essential to ensure that children of mentally ill parents grow up successfully with their family of origin.