With an apparent increase in the number of children born to parents experiencing mental illness many issues have been raised concerning parenting capacity and the welfare and development of these children. This has many implications for social work practice in both Children’s Teams and Community Mental Health Teams and also for future policy development and service provision. Within this dissertation it is my intention to explore that the mentally ill are indeed capable of parenting their children safely and effectively and attempt to disprove the suggestion that mentally ill parents are unsafe and incapable.
Adults with mental health problems are one of the most excluded groups in society, however many are also parents and may need support to care for their children safely (Garley et al 1997). This means that service provision must encompass the needs of both parents and their children and assessments must take into account the needs of both these vulnerable groups. The human cost for parents with mental ill health is in attempting to parent their children in the face of stigma and adversities. Social Workers do not only need to support these parents but they also need to challenge the stigmas and adversities perpetuated by society. Society has perceptions of people with mental illness and this is largely negative, with the greatest misunderstandings being the perceptions of the more severe mental health conditions. Severe mental health conditions such as schizophrenia although not as prevalent as the depressive disorders are thought to affect one in two hundred adults each year (Mental Health and Social Exclusion Report 2004) and these conditions have a wider impact on the lives of the family, friends and community.
It is widely recognised that one in four people of working age experience mental ill health at some point in their life, (Office for National Statistics 2008) but these problems can present in a variety of ways, depending upon the individual and their circumstances. What perhaps is most important to consider is how the person presents in relation to what is ‘normal’ for them. Any great changes in mood or behaviour can be important indicators of deterioration in mental health, but it is clear that it would be dangerous to view this in isolation. It is therefore important to recognise that we all may experience various degrees of mental difficulty at some point in our lifetime.
People with good mental health can; develop emotionally, creatively, intellectually and spiritually. They are able to initiate, develop and sustain mutually satisfying personal relationships; they can face problems, resolve and learn from them. They can be confident and assertive, are aware of others and have an ability to empathise; they can use and enjoy fun as well as laugh at themselves and the world. Good mental health is not something we have, but something that we do to take care of ourselves and value who we are as people (www.pmhcwn.org). However people experiencing mental illness do not always possess these attributes therefore need support to achieve wellness.
To make the distinction between people who have children and then develop a mental illness or those who have a diagnosed condition before they have children the focus will be on the experiences of those people with mental illness who become parents and so have already been living with their condition or diagnosis.
The aim of my dissertation will be to explore these issues by critically examining current research, practice, service provision and policy. This will be in the form of a literature based review where I want to question whether people with mental health issues can indeed parent their children safely. Firstly the Methodology used to assimilate the research will be examined with an explanation of the methods selected. Chapter One will define mental health, then focus on the historical context, policy and legislation and on the theories and approaches to ways of working considering the challenges that the social workforce face in supporting service users with mental health needs. Chapter Two will explore the experience of those parents with mental health problems; consider the capacity of people with mental health problems and the experiences of children of the mentally ill. This will be considered, from both a child’s and a parent’s perspective. Chapter Three will focus on the main themes to emerge from my research which are stigma, risk, resilience and attachment. The Results and Findings will be explored which will discuss the findings and present an overview of common themes which have emerged. The Conclusion will then draw together all the information gathered.
When approaching this dissertation the decision was made to conduct a literature review of the research currently available. This was because mental health is an area of interest and combined with a placement in a children’s team, where it became obvious that many parents experience mental health issues it was an opportunity to combine the two areas. Previously the author has worked in a statutory provision which was a service supporting children and young people experiencing mental health issues and also had a placement in a community mental health team. All of these experiences have made the author inquisitive to the difficulties that parent’s encounter when attempting to take care of their children and the views of services of their abilities to do so.
The search strategy used to locate appropriate material was to consider the various terms used when thinking about parental mental illness. Therefore a decision was made to search for the following terms; ‘parental mental illness’, ‘children living with the mental illness of parents’ and ‘capacity of parents with mental illness’. When further considering what needed to be learnt, the terms; ‘risk of children with mentally ill parents’ and ‘resilience of children with mentally ill parents’ were then explored as were ‘attachment of mentally ill parents’ and ‘stigma and mental health’. The concentration was on English speaking countries and so research was drawn together from Great Britain, Ireland, The United States of America and Australia. This was felt to be the most pertinent approach, as to broaden the search to further countries could create too much information and a difficulty in assimilating the research. Various databases were searched which included; Science Direct, Jstor and SwetsWise. The British Journal of Psychology, The British Journal of Social Work and Social Care Institute for Excellence proved to be invaluable as did the various mental health websites such as MIND. Government reports and Department of Health documentation added a further breadth to the research which was drawn together. This search produced a significant number of journal articles in the area which were appropriate for the purpose, and coupled with mental health websites and books on parenting capacity a rich variety of material was gathered. The information further obtained from legislation and policy documentation was also invaluable.
If there had been the time to explore this area in further detail it would have been suitable to have conducted a focus group amongst service users within the mental ill health community. From the research available it is clear that this research method was considered to be the most rewarding as service users felt the least threatened by the process (Garley et al 1997). It also garnered the most honesty from the participants and clarity of their experiences. They had felt safe in the knowledge that their recounting of their experiences would not be judged and their parenting abilities would be afforded due respect.
Another option could possibly have been to send out questionnaires to ascertain the level of support service user’s felt they were receiving from community mental health teams and children’s services. However this method may not have produced such a wealth of results as it would not have been a face to face intervention. When viewing research, non face to face approaches have sometimes not been as well responded to by prospective participants.
This chapter will focus on how mental illness is defined; look at the historical context of mental illness service provision, the legislation and policy documentation and approaches and theories to ways of working.
Defining Mental Illness
Mental illness can affect one in four adults of working age at some point in their life, according to the World Health Foundation (2001). This demonstrates how prevalent mental illness is within our communities and how anyone can be affected by it at some point in their lifetime. However mental illness is defined by society in a variety of ways; there is the legal definition, clinical definitions and popular public misconceptions. This section’s aim is to identify the three definitions of mental illness when considering the legal, clinical and public meanings.
Mental disorder is defined in a legal context as “arrested or incomplete development of mind, psychopathic disorder or any other disorder or disability of the mind” (www.yourrights.org.uk). There are various definitions of mental health and amongst these the Mental Health Act 1983 offers three different definitions for mental disorder: severe mental impairment, which is defined as “a state of arrested or incomplete development of mind which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned” (Mental Health Act 1983, Part 1). Mental impairment, which is defined as “a state of arrested or incomplete development of mind (not amounting to a severe mental impairment) which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned” ( MHA 1983, Part 1). Then psychopathic disorder which is defined as “a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned” ( MHA 1983, Part 1). However the 2007 Mental Health Act amendments changes the way the 1983 act defines mental disorder, so that a single definition applies throughout and abolishes references to categories of disorder( MHA 2007)
The clinical definition comes from ICD-10, which is the International Classification of Diseases which was approved by the forty-third World Health Assembly in May 1990 and came into use in World Health Organisation member countries as from 1994. It is the international model for diagnostic categorisation of all general epidemiological conditions and health management. Within the ICD-10 there is classification of mental illness and mental disorders and this is used by clinicians to diagnose and therefore treat those people with mental illness. The foremost definition used is that ” any of various psychiatric conditions, usually characterised by impairment of an individual’s normal cognitive, emotional, or behavioural functioning, and caused by physiological or psychosocial factors” (ICD-10 Chapter V).
When considering the public perceptions of mental illness, what is clear are the many negative perceptions of mental illnesses and disorders. The stigma that goes along with being labelled as having a mental illness can have far reaching consequences and needs to be challenged as a social injustice for this group (Cleaver et al 1999). Stigma is largely a social construct, in that society reacts negatively as a result of being fed sensationalist stories by the media. The Mental Health Knowledge Centre at the Institute of Psychiatry within the Maudsley Clinic London aims to promote change in public perception by addressing attitudes towards mental health conditions. The aim is that this will be achieved through ongoing public engagement activities and providing information for friends, families and carers of those with mental illness. Also initiatives such as World Mental Health Day endeavour to change public perceptions by bringing the conditions into the public arena.
People experiencing mental disorders are often excluded from some societal norms due to a lack of knowledge or fear on behalf of the community as the Mental Health and Social Exclusion Report of 2004 puts this “Mental health problems can be both a cause and a consequence of social exclusion” (Mental Health and Social Exclusion Report 2004 p11). What is known is that mental health problems can affect anyone at any point in their life. However the debates around the differing definitions of mental health are important to discuss in relation to exploring the issues for people with mental health problems who are also parents. Stereotypical views of people with mental illness are that they are violent, unstable, and irrational and therefore their abilities to parent are questionable. These perceptions have been perpetuated by an ignorant society and need to be challenged.
The Office for National Statistics has collected data to illustrate the prevalence of common mental health problems in the general population (see fig 1).
Figure 1: Office for National Statistics (2000) Psychiatric Morbidity Survey.
According to the Office for National Statistics the average age of early onset psychosis is twenty-two, but up to half of mental health problems start in childhood. For men, the age at which common mental health problems peak is forty-five to forty-nine years and for women fifty-fifty-four years. When looking at the statistics in terms of gender prevalence, women experience higher rates of problems than men and their experiences tend to last longer with greater occurrences of relapse. However what is known is that young men aged twenty-five to thirty-four are the highest risk group for suicide (Office for National Statistics 2000).
Mental health illness is referred to in a variety of ways in the literature and research; therefore for the purposes of this paper, mental illness, mental ill health and mental health problems will be used interchangeably with the main emphasis being placed on the conditions of schizophrenia and psychosis rather than the depressive conditions.
Schizophrenia is a diagnosis given to some people who are experiencing severely disrupted beliefs and experiences. During an episode, a person’s experience and interpretation of the outside world is disrupted. They may experience hallucinations, lose touch with reality or see or hear things that are not there and act in unusual ways. An episode of schizophrenia can last for several weeks and can be very frightening (www.rethink.org). An episode of psychosis can be experienced in much the same way.
However to appreciate contemporary understanding of mental illness, the historical context needs to be explained and how parents have been viewed by society.
Historically those individuals who experience mental illness may be treated for their condition by their local General Practitioner in the local community, however those individuals who require more intensive interventions may fall under the support of The Mental Health Act 1983. Following years of the institutionalisation of individuals with mental health disorders came the Mental Health Act 1983, which made provision for these people to be supported in the community. This important legislation made provision for the safety and well being of those people experiencing mental distress. For the first time, mental illness was recognised as a condition that could be managed in the community and newly formed community mental health teams would be the people to assist. The Mental Health Act 1983 made provision for individuals needing treatment to be detained under section, which meant that they could be legally detained to ensure that appropriate treatment was administered either in the form of therapeutic intervention and or medication. This act was further amended in 2007, where one of the main amendments was to make provision for Community Treatment Order (CTO). This declared that a patient could be re-called for treatment in hospital if they had been discharged into the community and were not complying with the restrictions of their order.
Policies imposed by local authorities must work within the guidelines of both The Mental Health Acts 1983 and 2007 and The Children Act 1989 in conjunction with the Care Programme Approach 2008. These government laws state how the care and treatment of people with mental health and the care and protection of children should be managed. A comprehensive care plan should address all the issues around the person and allow for their ability to parent by assessing their parenting capacity.
Every Child Matters (2002) was one such provision developed to support children,” the main duties being to cooperate and improve well-being, and to safeguard and promote the welfare of all children in England” (www.everychildmatters.gov.uk ). Every Child Matters was developed following Lord Laming’s report of 2002 which was implemented following Victoria Climbié’s death in 2000. He highlighted within his report that a lack of integrative working across the different services and agencies had contributed to Victoria’s death. Every Child Matters legislates for improving information sharing between agencies to ensure the safety of children known to local authorities and this would be done by reducing the technical difficulties with the different interfaces used by the diverse services (ECM 2002). A huge challenge to overcome with much work still needed in this area as health, education and social services remain largely fragmented (ECM 2002). To attempt to overcome this, a common assessment framework was devised across services to ensure the information followed each child and reducing the necessity for duplication of information. These tools were then used to ensure that if a parent came to the attention of mental health services then the worker would be able to instantly determine if their children were also known to children’s services.
Legislation and Policy Documentation
The National Service Framework for Mental Health, from the Department of Health (1999) document states that local authorities have a duty to provide effective services for people with mental illnesses. Its aim is for individuals, who may or may not be parents, with a severe mental illness to be able to access and receive the range of mental health services that they need and consequently crises will be anticipated and averted. Therefore even if a parent is considered to pose a threat to their child they should be maintained with parenting support in advance. The recommendation being that there will be the integration of health and social care services with a strong emphasis on Interprofessional collaboration and this joined up working will promote the active participation of service users.
The Mental Health and Social Exclusion Report of 2004 activated by the Office of the Deputy Prime Minister detailed in action sixteen “better support for parents and their children” (Mental Health and Exclusion Report 2004 p105). This challenge was taken up by the Action Sixteen Group who would review its implementation. This body comprised of ;the Social Care Institute for Excellence, Barnardos, the Department of Health, National Children and Adolescent Mental Health Services Support Service, Family Action and the Mental Health Commission. This membership of the Action Sixteen Group brought together professionals who were dedicated to improving outcomes for parents affected by mental illness and their children. The key messages to emerge from their discussions were that the mental health services should ‘think family’ (www.scie.org.uk). This would be achieved by improved awareness, sharing of information across services and the development of resources for positive practice.
Action Sixteen worked together to review the existing provisions for parents with mental health needs, including the needs of mentally unwell parents who were also belonging to an ethnic minority group and or were also disabled parents. It determined that parents need to be enabled to lead fulfilling lives in the way that they chose. That sigma and discrimination must be challenged and the rights of parents must be promoted, social exclusion must be confronted through implementing evidence-based practice and getting the basics in order must be a priority (Fowler et al 2009). This means enabling mentally ill parents to have access to decent housing, advice on finance and benefits, training and employment. (Fowler et al 2009). All of this needs to be approached from an informed viewpoint and the most appropriate theories and ways of working considered.
Ways of Working
The challenges for the social work profession to assist mental health service users are immense, diverse and complex. When approaching work with any vulnerable service user group it is important for social workers to maintain their social work values and recommend a holistic approach to their interventions with families (GSCC codes of Practice 2002). This would mean balancing practical and emotional support, offering appropriate counselling and working in a therapeutic way to best support parents with mental health needs (Darlington et al 2005). As previously discussed parents with mental health issues may experience social exclusion or isolation and it is a challenge for social workers to support these individuals to maintain a more integrative life. They also need to be aware of the power relationship between those who provide and those who access mental health services and the disempowering consequences of being labelled a mental health service user (Williams and Keating 2000). Research studies have shown that it is a considerable challenge for people with mental illnesses to sustain and maintain social contacts and relationships (Huxley and Thornicroft 2003). Further research into this area as to how parents with mental illnesses can be encouraged to lead a more integrative life is needed.
The requirements for the social work workforce within the mental health sector are clear guidelines for working in an integrated team, with strong leadership and comprehensible policies to enable improved multi agency working. This is further challenged by maintaining and preserving the separate skill bases of each profession within a community mental health team. Community psychiatric nurses (CPN) have trained to specifically achieve a qualification, as indeed have their social work colleagues and the’ blurring’ of roles may create disquiet amongst individuals. With the new Approved Mental Health Professional (AMHP) role being made available to professionals from other disciplines this may create further challenges within multi-disciplinary working.
Only those professionals trained to become a health professional have the ability to administer medication and a large part of their role in working with the mentally ill is to ensure medication compliance. However medication is best supported if it works in conjunction with therapies (www.rethink.org) and the most recognised therapy to assist with mentally unwell individuals is Cognitive Behavioural Therapy (CBT). Cognitive Behavioural Therapy was developed by Aaron Beck (1921- ) in the 1960’s as a psychological approach to assist people in changing how they thought and felt (Beck 1975). This approach is widely recognised today as the foremost ‘talking therapy’ when working with the mentally ill.
Any professional will need to approach working with a mentally ill service user from an informed position. The experiences of the vast majority of people with mental health problems are that they are labelled. Labelling theory was first applied to the term “mentally ill” in 1966 when Thomas Scheff’s book- Being Mentally Ill was published. Scheff’s claim was that mental illness perceptions needed to be challenged as mental illness was a social construction. He purports that no one is deviant and no action is deviant unless society deemed it to be so and that symptoms of mental illness are regarded as violations of societal norms (Scheff 1966), so to challenge society’s view of their perception of mental illness is one way to assist those with mental illness and the stigma they experience as a result of labelling.
When considering a parent with mental illness and the approaches to working with these individuals a holistic approach would appear to be the most pertinent to consider appropriate. This means taking into account the persons physical and spiritual health as well as their mental health needs (Hunt 2009). The Care Programme Approach is now recognised as the best way to do this. The Care Programme Approach 2008 or CPA as it is referred to within services is a way of developing a plan of work individualised to each person’s needs. The Care Programme Approach has four main elements as defined in “Building Bridges: A guide to arrangements for inter-agency working for the care and protection of severely mentally ill people” (DoH 1995 p1). It works by assessing a person’s needs and then developing a plan in response to those needs; the plan is then implemented and reviewed regularly to ensure that it is continuing to meet the individual’s needs (www.dh.gov.uk).
The latest development in policy implementation is New Horizons; a government program of action which has been launched to improve the mental well-being of people in England and drive up the quality of mental health care. New Horizons is a comprehensive initiative that will be delivered by local government, the voluntary sector and professionals with an aim of creating a society that values mental health. This will be achieved by ensuring the foundations of good mental health begin in childhood and continue through the lifespan, emphasising the importance of prevention as well as treatment and recovery (New Horizons 2009). All professionals will be encouraged to identify children whose parents may be experiencing difficulties and signpost them to appropriate services.
The next chapter will consider how policy and legislation works in supporting parents with mental ill health by considering their experiences, how their capacity is measured and how their children view both their parent’s illness and treatment.
This chapter will focus on the experiences of parents with mental health problems, their ability to parent, their parenting capacity and the experiences of children of the mentally ill. The numbers of parents who experience mental health issues is not clear but it is estimated that in excess of thirty per cent of the population may be affected.
Experience of Parents with Mental Health Problems
When considering the research available, what is clear is that the focus has been mainly on the female experience as women were found to be the main caregivers, Nicholson et al (1998). In a study, using focus groups with mothers, to explore the problems they faced as a result of their mental illnesses Nicholson et al concluded that the experiences these mothers recounted detailed ” their concerns, their struggles and their successes” (Nicholson et al 1998 p 638). They discussed the anxiety of stigma and the worry of having their children removed by social services as well as the everyday struggles of looking after children (Nicholson et al 1998).
In a study, to explore the experiences of new mothers Mowbray et al (1995) found that motherhood was a role of great significance for many women with mental health problems. The mothers in their study articulated just how important the experience of being a mother was to them, the joy that it brought for them and the growth in personal development it produced (Mowbray et al 1995). What is known is that parenting is viewed by society as being highly valued and although this is a common thread to all societies and cultures, most perceptions are that parents with mental illness are viewed negatively, (Mowbray et al 1995). Furthermore as parents with mental health problems are de-valued by society and their parenting capacities and abilities are questioned they fear that their children will be removed from their care therefore they avoid contact with social services even if they are aware they need support. This all adds to the stress that parents experience in coping with their mental illness and the demands of parenting. Nicholson et al (1998) found that parents felt unable to ask for the support they may need due to the fear that social services would remove their children from their care. This was a great fear for the mothers in this study but further studies have also corroborated this, for example Cleaver et al (1998) reviewed data from research and discovered that forty- two per cent of children who were initially referred to child protection services following an assessment of their parent(s) mental health became subject to care proceedings. This indicates an equal fear on behalf of the professionals involved with parents with mental ill health, the need to protect balanced against the needs of the parent to maintain normal family life. Parents have therefore identified that they will be viewed as flawed by society and perhaps incapable of fulfilling one of society’s most treasured roles and have their parenting abilities and capacity questioned (Ackerson 2003).
Parents with mental illness may have difficulty in caring for their children because they feel a need to focus on their own needs or are unable to recognise their children’s needs and this can impact on their parenting capacity. Other influences can also impact such as relationship breakdown, poverty, unemployment and social exclusion.
There is a real difficulty in attempting to establish just how many parents have a diagnosis of schizophrenia or psychosis although it is estimated that as many as nine million adults may have a mental health need (www.family-action.org.uk ) Many of these illnesses go undetected with some parents refusing to acknowledge that they have a problem for fear of the consequences for their children (Beardslee et al 1983). For many parents the greatest fear being the removal of their children by social services. This is largely due to much of the current service provision being aimed at protecting children considered to be at risk from harm rather than supporting mentally ill parents to overcome the disabilities that hinder their parenting role. This could be better supported by intervention before a risk to the child becomes apparent (Kearney et al 2003). This is in direct conflict with the Children Act 1989, which recommends that wherever possible parents should be supported to care for their own children at home. This all creates a culture of fear for parents, as they cannot be honest about what they are experiencing as this may result in the removal of their children. However what is known is that there is a significant number of parents whose children are known to social services have a mental health problem (Crossing Bridges 1998).
Having a mental illness can impact on the parents’ ability to care for their children in a variety of ways such as; being unable to provide food, clothing, shelter and warmth or indeed be able to keep their children safe from harm (White et al 1995). However if a parent makes what is perceived to be an unwise or eccentric decision this does not necessarily mean that they are lacking in capacity (Mental Capacity Act 2005).
All parents are expected to provide; a safe physical and a secure emotional environment for their children, they are