Parents with Mental Illness : Psychosocial Rehabilitation

by SAMHSA

(Page 18 of 20)

In the past two decades, psychosocial rehabilitation (PSR) services for adults with mental illness have become an increasingly important component of comprehensive mental health services. The goals of PSR services are to help those with mental illness participate optimally in their chosen adult life roles. PSR services are guided by a philosophy that stresses client choice and empowerment, places an emphasis on client strengths, promotes community integration, and provides on-going services in the context of a client-provider relationship characterized by partnership and advocacy.

PSR interventions use either of two general approaches: (1) skills training approaches that aim to enhance the capacity of individuals with mental illness to perform the tasks and activities required of their chosen life roles; and (2) environmental modification approaches that aim to provide or enhance resources and supports, and/or reduce barriers so that individuals with mental illness may participate optimally in the living, learning, working and socializing environment of their choice. Many PSR services incorporate both approaches.

A range of PSR services are effective in enhancing role participation among adults with mental illness. These include supported employment, education and housing services, intensive case management services, life skills (e.g. social, recreational, pre-vocational) training approaches, medication and stress management approaches, and psychoeducation for consumers and family members. With its emphasis on optimal participation in normal adult life roles, PSR holds promise as a guiding framework for services for parents with mental illness. Yet, parenting as a life role has been largely ignored by PSR service providers. While specific services that support participation in life roles, such as employment, have existed for many years, analogous services to support parenting have not been developed within the field.

The potential of PSR approaches to services for parents with mental illness has been noted. Nicholson and Blanch (1994) argue for a comprehensive approach to services that includes assessment of parenting capacities, involvement of the parent in decisions regarding pregnancy and parenting status, efforts to help parents develop effective parenting skills, and the development of both informal and formal supports to enhance clients' capacity to parent. In a review of interventions for mothers with serious mental illness, Oyserman, Mowbray and Zemencuk (1994) maintain that services reflecting a PSR philosophy must: 1) assess mothers' environments, including quality of housing, social networks, and the availability of social/emotional supports, 2) assess mothers' strengths and the meaning of parenting for women with serious mental illness, 3) assess barriers to service participation and attainment of parenting goals. More recently, Nicholson and Henry (in press) suggest that targets of rehabilitation interventions should be determined in partnership with mothers, through assessment and consideration of mothers' parenting goals.

Few PSR agencies have developed services or programs specifically for parents with mental illness. One of the oldest and most well known programs is the Mothers' Project at Thresholds, a comprehensive PSR agency in Chicago (Zeitz, 1995). The Mothers' Project provides comprehensive center, community and home-based services for mothers with mental illness and their "at risk" children up to the age of 5. Children attend a therapeutic nursery program that emphasizes social-emotional and cognitive development; mothers participate in the nursery program where appropriate parenting skills are modeled. In addition, mothers are provided comprehensive case management services and can take advantage of a full array of PSR services, including supports for employment, recreation, education, and life skills training. Support services for other family members (e.g., fathers, grandparents) are also provided. As noted in the section of this paper on Child Outcomes and Therapeutic Intervention, evaluation of the Mother's Project has revealed promising outcomes for mothers and children.

There are likely many reasons why PSR agencies are not adequately addressing the needs of parents with serious mental illness and their children. These may include an actual lack of information about the parenting status of program clients, and a lack of knowledge among PSR providers regarding approaches to support parents. Parenting supports are rarely mandated in publicly funded PSR agencies, thus resources for such initiatives are limited. Moreover, many states have separate adult and child funding streams, precluding the provision of integrated services to parents and children by PSR agencies funded to serve adults. Lastly, clients in PSR agencies may be reluctant to seek help with parenting because they fear possible custody loss of their children.

SUMMARY: Parenting is a primary and critical life role for many women and men with mental illness that must be acknowledged within the milieu of psychosocial rehabilitation. The PSR approach has a good track record in supporting adults with mental illness in developing skills in other life roles, and holds great potential for supporting the development of parenting skills among adults with mental illness.

RECOMMENDATIONS: Prioritize parenting as a fundamental life role, much like employment or participation in social networks, with a focus on identifying strengths that can be incorporated into a comprehensive approach to rehabilitation services.

Legal System

Having a mental illness is an added disadvantage in the legal system. Basic civil rights such as the right to vote or serve jury duty can be denied simply based on the diagnosis of a mental illness (Burton, 1990). In many states, the diagnosis of mental illness alone justifies the removal of children from their parents' care, and the termination of parental rights (Burton).

The determination of "parental competence" or the impact of a particular parent's mental illness on his or her capacity to parent, is complicated by the lack of an accepted definition, the irrelevance of traditional psychological instruments, situational influences, and the lack of normative data. Concerns have been raised regarding the use of parent evaluations in child protection decisions. These authors found numerous substantive limitations in the comprehensiveness and content of parent assessments in a sample of 190 mental health evaluations performed in conjunction with a major urban juvenile court system. Bias regarding mental illness and parenting may be introduced into the Court's findings. Decisions with great consequence for adults and children are made with little basis in science, and are subject to much individual discretion. Comprehensive multidisciplinary evaluation team models are recommended, but may be difficult to fund or staff.

Key informants in the legal arena observed that a parent's diagnosis of mental illness can have a profound impact in divorce proceedings when custody and visitation determinations are made. Divorcing parents are faced with multiple stressors including the trauma of loss, grief, and financial burdens, which are usually more extreme for women than for men. Key informants suggested that mothers experiencing mental illness, particularly those whose ability to maintain employment is compromised, are often unable to afford the costs of divorce, e.g., lawyers fees, evaluations for the children, child care, missed work, and are therefore at a disadvantage. Many lawyers are reluctant to take divorce or custody cases where a parent has a mental illness. Most often this fear stems from a lack of knowledge about mental illness and how this relates to a person's ability to be a good parent. Situations where supervised visitation is necessary are also problematic because supervisors are both costly and difficult to find.

New England is home to efforts beginning to address the issues of adequate representation for individuals with mental illness in family law matters. The Clubhouse Family Legal Support Project in Massachusetts is co-led by Employment Options, Inc., a psychiatric rehabilitation clubhouse, and the Massachusetts Mental Health Legal Advisors Committee. A legal fellow, co-funded by the Massachusetts Bar Association and the National Association of Public Interest Lawyers, represents the needs of parents with mental illness, specifically those at risk of losing custody or contact with their children. As a staff member in the clubhouse, the legal fellow handles a variety of situations including custody and visitation issues, dealing with restraining orders, and negotiating housing issues that may mitigate against families reuniting. Funding also provides for the training of attorneys and judges regarding parental competence and mental illness.

In New Hampshire, the Disability Rights Center, and the Department of Health and Human Services Division of Behavioral Health are working together with peer support representatives, mental health consumers, the NH Bar's Legal Services program and Family Law Section; NAMI-NH; LARC; New Hampshire Children's Alliance; Child and Family Services of NH; the Institute on Disability of the University of New Hampshire; the Division of Children, Youth and Families; Dartmouth Psychiatric Research; and private attorneys with family law practices as the Coalition for Family Law and Mental Health (Sanford, 2000). The purpose of the Coalition is to increase the availability of attorneys for individuals with mental illness who have family law issues; and to make reforms in the family court system in New Hampshire. Funding has been obtained from the NH Bar Foundation, NH Charitable Foundation, the Division of Behavioral Health and the Division of Children and Youth Services to support the hiring of a director, and to focus on increased education and training.

SUMMARY: Adults with mental illness, and particularly those who are parents, are at a disadvantage in the legal system. Because of the stigma attached to mental illness, general ignorance of the true impact of mental illness on day-to-day functioning, and the lack of appropriate evaluation methods, assumptions and decisions are made that may not be based in fact or supported by science. There is a lack of knowledge about the legal rights of adults with mental illness. Existing laws often work against parents with mental illness, whose access to their children may be denied, simply by virtue of their being labeled with a psychiatric diagnosis.

RECOMMENDATIONS: Create a standardized training model to educate lawyers and judges regarding the abilities of parents with mental illness and the needs of their children, and the rights of adults with mental illness and their families, specifically as they relate to custody, visitation and divorce. Provide accessible and affordable legal services to adults with mental illness. Develop the empirical foundation and relevant assessment procedures essential to improved parent evaluation practice.

About the Author

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