History: from neglect to prevention and promotion

Western psychiatry has a dark history of placing mentally ill people in asylums, and clinicians paying no attention to their children. During the 1950s and 1960s, new antipsychotic drugs transformed psychiatric treatment, enabling patients to live outside institutions and re-enter their community; this usually meant that they lived with their families. While an important transition, this created challenges for families, whose own needs were often not considered. If the patient had children, child-protective services were often involved.

The rise of family psychiatry and family therapy in the 1970s and 1980s focused on helping family members support the ill parent, though this usually meant the spouse and parents of the adult client rather than children. Later, family therapy examined the family from a systems view, where family dynamics was seen as the cause or enabler of an individual’s psychiatric disorder. In this model, therapy focused on changing family dynamics rather than on individual pathology. Children of parents with a psychiatric disorder might be involved, but were generally not the primary focus.

In regard to research, the first studies documenting the risk to children in families with parental psychiatric disorder were published in the 1950s and 1960s (Buck and Laughton, 1959; Rutter, 1966). These have since been followed by several longitudinal studies (see, for example, Weissman et al., 2006). Recent research focuses on the processes that either promote children’s well-being or protect them against the influence of various risk factors within a resilience framework. Accordingly, there is increasing interest in the promotion of young people’s mental health alongside the development of various prevention or early-intervention programs for families (Siegenthaler et al., 2012).

Why work on parenting with clients in adult mental health services?

Parents are crucial in creating a functional, well-adjusted family and are essential for initiating change in families; this is also the case for families where a parent has a psychiatric disorder. The transmission of risk from parents to children is significantly mediated by the impact of parental symptoms on parenting and parent–child interactions (Compas et al., 2010; Hosman et al., 2009). This means that focusing on parent–child interactions and relationships provides an ideal opportunity for early intervention to improve outcomes for children. Studies reporting on children’s outcomes in support groups also highlight the importance of involving parents when working with children within a prevention framework (Compas et al., 2010; Van Santvoort, 2013).

In adult psychiatry, clinicians know about and subsequently treat a parent’s psychiatric symptoms; these meetings provide an opportunity to help the parent and family to make sense of the symptoms and cope in the context of family life. Therefore, adult psychiatry needs to be at the forefront in impeding the intergenerational transmission of mental illness from parents to children, as well as for the early identification of children in need of support.

Furthermore, acknowledging and supporting a client’s parenting role can assist in the client’s own recovery. Swartz et al. (2008) suggest that if treatment embraces parenting and concerns about the children, it is more effective than practice as usual. Including parenting in parents’ treatment protocol has also been shown to increase their treatment motivation (Solantaus et al., 2009). Tjoflåt and Ramvi (2013) suggest that caring for children allows clients to develop self-esteem and feelings of competence, while Ackerson (2003) found that a focus on parenting may serve as a reinforcer to maintain medication or treatment regimens. These studies suggest that parenting is a facilitator, often unappreciated, of a client’s recovery.

Relationships between parents and children are bidirectional, which means that the behavior and well-being of one family member will affect others. A vicious cycle can be created between parental and child problems, but also a virtuous cycle is possible – that is, between parental and child recovery – with one reinforcing the other (Compas et al., 2010; Weissman et al., 2006). Swartz et al.’s study (2008) suggests that parent recovery precedes child recovery, highlighting the need for timely and effective treatment for the parent. Conversely, Forman and colleagues (2007) found that the treatment of a parent’s depression, even successfully, was insufficient to change the mother–infant relationship. Interventions that focus on only one family member (the child or the parent with the psychiatric disorder) may be insufficient to address maladaptive family functioning. Similarly, Kelley and Fals-Stewart (2002) found that for parents with a substance-abuse disorder, couple-based therapy with a focus on dyadic adjustment recorded greater benefits for children than individual-based therapy, perhaps because improvements in the couple’s relationship positively affected family dynamics. These studies underline the need to include parenting and family relationships in standard treatment protocols in adult psychiatry.

Issues when working with parents

The stigma associated with psychiatric disorders (see Chapter 6) means that parents as well as clinicians might be reluctant to discuss psychiatric illnesses in the context of family life. Moreover, in some countries, a psychiatric disorder is a legally accepted reason for custody loss (see Kaplan et al., 2009) – we believe that this is a breach of children’s and parents’ human rights. Loss of custody and children’s out-of-home placement are warranted only in cases where problems lead to child abuse and neglect and the situation cannot be helped with family support.

Social class and ethnicity influence how families understand and manage the disorder. One study found that Hispanics and African-Americans caring for a relative with a psychiatric disorder sought out other family members for advice, while European-Americans turned instead to mental health professions (Guarnaccia and Parra, 1996). Every family is unique and parents too will vary, in terms of their attachment history (how they were brought up themselves); their own experiences of trauma, loss, and grief; and their views on being a “good” parent. These families often face other forms of disadvantage, such as stigma, inadequate housing, and poverty, and these are all issues that need to be considered when working with parents. For example, if parents are experiencing severe marital difficulties or are having difficulty in finding a place to live, they may not have the capacity to discuss their disorder with children.

Even if parents are ready to reflect on their disorder in the context of family life, many clinicians, across disciplines and agencies, do not have the skills or knowledge to address their needs (Maybery and Reupert, 2009). Accordingly, there is an urgent need to offer accessible, effective professional development in this area (see Chapter 27). Working with families can be both professionally and personally challenging. For example, even though clinicians might be working with clients on parenting, they need to be able to appreciate simultaneously children’s and parents’ needs and support them both.

Most services identify and approach families when child abuse or neglect is a concern, or when the child presents with psychiatric or behavioral problems. While essential, both approaches are essentially reactionary, and miss a critical opportunity for prevention and early intervention. Similarly, siloed agencies or funding arrangements dictate that many services are able to see and treat only eligible parents or children, but not both (Nicholson et al., 2001). Working effectively with families where a parent has a psychiatric disorder presents a major paradigm shift in traditional psychiatric services, from a focus on individuals to family ecology and from treatment to prevention and promotion. This means that even though individual clinicians might want to respond to the needs of families, they are constrained by multiple organizational barriers (Maybery and Reupert, 2009; Rynning-Myrvoll, 2013). See Section 5 of this book for more on these matters.

Initiating a discussion with parents about their children and parenting

The first, critical step for all clinicians is to identify which of their clients are parents, including expectant parents, a protocol that is yet to become standard practice, especially for fathers and noncustodial parents. The next step is to initiate a discussion about and support for parenting and children. If discussing parenting and children is not a part of standard services, such discussions can be somewhat surprising or even alarming, especially if parents are concerned about the involvement of child-protection services or if clinicians present their inquiries as if problems were to be expected. However, when conversations are respectful, most parents are relieved.

This example raises a critical issue. Why had the mother not initiated discussions about her children if she had concerns about them? There are several possibilities. She may have learnt to conform to what was expected (permitted) to be discussed in therapy, she may have thought that a psychologist in adult psychiatry would not have the skills to support parenting and children, or she may have been worried about the child-protection services becoming involved. This example highlights the need for clients to feel that they and their children are safe, that talking about parenting is standard practice, and that there is support for clients in their parenting role. Consider the following as the beginning of a conversation (the asterisks refer to the following explanations):

Some parents might have had negative experiences in talking to clinicians in the past. It is important to be honest about this and indicate that working with clients on family matters is relatively new for mental health clinicians but is increasingly seen as important for them and their family. This concern may allow the clinician to ask, “What can we do together to make sure it’s better this time?”

It is also important to address potential parental hesitancy. Some parents are concerned that children might find information about their parent’s illness traumatizing; some parents believe that their children are too young to understand. These concerns are valid and should be taken seriously. It can be difficult to understand psychiatric disorders. Children need support to understand what is going on in their family, what is happening to their parent, and how they can relate to events and respond in different situations, such as when the parent is unwell. Because of stigma and its impact on families (Hinshaw, 2005), parents may need support in talking about psychiatric disorders within the family. Clinicians need to gently let the parent know that children will be trying to make sense of what is happening in the family even without the family openly discussing it. In a recent interview-based study, one mother with an eating disorder reported that even though she regularly purged, a behavior her 4- and 5-year-old children called being “sicky sick,” she did not talk to them about this, as “they wouldn’t understand” and “they didn’t ask questions about it” (Stitt and Reupert, 2014). The mother did not recognize that her children had their own language for what was happening and were trying to make sense of her behavior. The clinician may ask the parent what their children have seen or heard, how they have responded, and what they might think about it, and may highlight the importance of helping young people make sense of what is happening in their family so they do not worry or feel responsible. The next step in the process is then to discuss and make plans about how the family members can cope with the symptomatic behavior and manage daily life during illness episodes.