This Web site is a component of the SAMHSA Health Information Network

Enter Keywords Choose Website This Site Mental Health at HHS All Mental Health

Online Publications Order Publications National Library of Medicine National Academies Press Publications Homepage

printer friendly page e-mail this page bookmark this page shopping cart  current or new account

This Web site is a component of the SAMHSA Health Information Network.

Critical Issues for Parents with Mental Illness and their Families

Chapter VI

What Can We Learn From Other Systems and Fields?

CRITICAL ISSUE: The families of parents with mental illness, and the families of children with serious emotional disturbance have overlapping risk factors and service needs (Katz-Leavy, Nicholson, Banks, Hinden & Lambert, 2001 presentation). The needs of adults and children living with parental mental illness have been traditionally met by services and providers in several systems. Knowledge about psychiatric disorder in adults, serious emotional disturbance in children and adolescents, and the issues of families living with mental illness must be shared with relevant systems, services and providers. Likewise, efforts to meet the needs of individuals and families originating in arenas other than mental health, can inform efforts in the mental health services arena.

The current "state of the science" in these related fields of study was determined through both an extensive review of the literature and interviews with over thirty key informants. The resultant body of knowledge highlights both critical issues in the field and recommendations for action.

Child Welfare
Parenting services are often considered to fall under the purview of the child welfare system (Nicholson et al., 1993). The assumption that all parents with mental illness abuse their children is powerful and dangerous. Research investigating the link between parental mental illness and child abuse seems to most frequently implicate personality disorders (especially antisocial personality disorder) and major depression as risk factors for child abuse (Bland & Orn, 1986; Chaffin, Kelleher, & Hollenberg, 1996; Dinwiddie & Bucholz, 1993; Famularo, Kinscherff, & Fenton, 1992a, 1992b; Taylor et al., 1991). However, alcohol and/or substance abuse have also shown strong associations with child abuse (Chaffin et al.; Dinwiddie & Bucholz; Famularo et al.), especially when occurring comorbidly with serious mental illness (Bland & Orn).

There are a number of environmental stressors that often accompany serious mental illness that may increase the risk that parents with mental illness will abuse their children. Researchers have reported that mothers with serious mental illness are likely to be living in poverty (Zemencuk et al., 1995). They often have marital difficulties, and are likely to be divorced or never married (Downey & Coyne, 1990; Mowbray, Oyserman & Ross, 1995a). Many have conflicts with extended family and are isolated from social supports (Cox et al., 1987; Nicholson et al., 1998b).

There are also factors that appear to mitigate the risk of child abuse for parents with mental illness. A recent study (Mullick, Miller, & Jacobsen, 2000) found that the level of insight a mother has into her mental illness is significantly negatively correlated to her risk of abusing her children. Insight into mental illness was also significantly positively correlated with ratings of maternal sensitivity.

Research on the relationship between parental mental illness and child abuse is limited in several ways. Most studies are based on samples of parents who have been determined through the child welfare system or the courts to be abusive, or who report themselves to be abusive. The goal of these studies is to describe profiles of child abusers, or to identify risk factors contributing to an increased likelihood that abuse will occur (Bland & Orn, 1986; Chaffin et al., 1996; Dinwiddie & Bucholz, 1993; Famularo et al., 1992a, 1992b; Taylor et al., 1991). These studies do not actually tell us what percent of parents with mental illness abuse their children, but rather tell us what percent of parents who abuse their children have mental illness. There is no way to know what proportion of the total population of parents with mental illness these parents represent.

SUMMARY: While the prevalence of certain types of mental illness, e.g., antisocial personality disorder or depression, particularly when co-occurring with substance abuse, in samples of known child abusers is higher than what might be expected in the general population, these data do not tell us about the prevalence of child abuse in the families of parents with mental illness. We know more about the likelihood that parents who are child abusers will have mental illness than we know about the likelihood that parents with mental illness will abuse their children. Serious mental illness often occurs together with many environmental stressors that increase the risk of abuse to children, suggesting complex sets of relationships among multiple contributing factors.

RECOMMENDATIONS: Research is required to investigate the likelihood of abuse and neglect in families in which parents have mental illness, and to fully understand the relationship between mental illness and child abuse, in the context of a constellation of factors contributing to risk for children and families. Fortunately these factors may suggest many avenues for intervention.

Early Intervention/Head Start Federal legislation mandates family-centered Early Intervention (EI) services for infants and toddlers (ages zero to three) with established diagnoses or demonstrated developmental delay. Some states serve infants and toddlers at-risk for developmental delay as well (Shonkoff & Meisel, 1991). Risk factors can be both physical, such as low birthweight or exposure to infectious diseases, or contextual, such as living in poverty or having a parent compromised by illness.

The prevalence of parental mental illness in families receiving Early Intervention services is unknown, but anecdotal reports from EI providers suggest a substantial subgroup. Research indicates that children with a parent with a mental illness are at risk for development of emotional or behavioral difficulties; providers of early intervention services have noted the potential deleterious effect of parental depression on children's early development (Goodman & Gotlib, 1999; Osyerman et al., 2000). Research has shown EI to have moderate positive effects in children, particularly in cognitive and language outcomes (Shonkoff & Hauser-Cram, 1987). In addition, EI programs focusing on parental participation appear to be more effective than those minimizing or disregarding the role of parents (Shonkoff, Hauser-Cram, Wyngaarden Krauss & Upshur, 1988).

Started over 30 years ago, Head Start exemplifies the EI philosophy by incorporating the "whole child" perspective of family-centered interventions, working towards wellness for all family members in at-risk situations. Head Start promotes good physical, cognitive and social health, proper motivation, and a parent's ability to participate in his or her child's learning to foster positive outcomes for children entering school (Zigler, 1998). Included in the Head Start philosophy is the belief that a child's community, including family, school and supports, must be part of the path to wellness.

Head Start's target population - children and families in poverty-is similar in many ways to families in which a parent has a serious mental illness. Both groups are parenting in compromised circumstances that often include low income, unsafe housing, un- or under- employment, and inadequate social networks. While the prevalence of mental illness among Head Start parents is unknown, one administrator of a Head Start program estimated that a third of the families she sees have a parent with depression.

SUMMARY: Children in families in which a parent has mental illness are likely to be at developmental risk, and are likely to be a significant sub-set of the larger Early Intervention population of families. Early Intervention or Head Start efforts have not systematically assessed or focused upon the needs of the possibly substantial subgroup of families in which children are living with parents with mental illness.

RECOMMENDATIONS: Early Intervention programs are an appropriate service option for at-risk children in families where a parent has a mental illness. Advocacy efforts are needed to ensure that families are considered for these services. EI service providers need education about the challenges faced by parents with mental illness, including those related to mental illness itself, as well as issues such as stigma and poverty, that may be barriers to full participation in services.

Substance Abusing Pregnant Women and Mothers
A significant percent of adults who abuse substances also have co-occurring mental health issues, and rates for comorbid substance abuse among adults with mental illness are high (Kessler et al., 1997). Primary diagnoses include major depression, panic disorder and post-traumatic stress disorder (Helzer & Pryzbeck, 1994). Women who abuse substances are also at increased risk for attempting suicide (Evans & Lacey, 1992). There is likely to be considerable overlap between mothers who abuse substances and those with mental illness.

Similar to women with mental illness, substance-abusing women often face a myriad of social, emotional, psychological, and physical problems, in addition to pragmatic concerns about housing, employment, transportation and finances (Alexander, 1996; Finkelstein, 1994; Reed & Mowbray, 1999). Pregnant and parenting women have a special set of circumstances to consider. Substance abusing pregnant women are at increased risk of contracting sexually transmitted diseases, HIV and Hepatitis B (Alexander; Finkelstein, 1993). Possible outcomes for children include prematurity, low birth weight, Fetal Alcohol Syndrome and HIV exposure, all of which have short- and long-term consequences (See for example Kliegman, Maduna, Diwi & Eisenberg, 1994; Sonderegger, 1992). Children whose parents abuse drugs and alcohol are more likely to be abused and neglected that children whose parents do not (National Center on Addiction and Substance Abuse, 1999). Substance abusing pregnant women and mothers are less likely to seek prenatal or general health care, due to stigma, denial, the lack of gender-specific treatment options, and the dearth of treatment options for mothers with their children (Finkelstein, 1994; Reed & Mowbray). In addition, many substance abuse programs will not enroll pregnant and parenting women.

Substance abuse treatment strategies were originally designed for male substance abusers. This trend changed in the mid-1970s, with the passage of Public Law 94-371 mandating the creation of specialized treatment programs for women (Finkelstein et al., 1997). As a result, research and programming specific to substance abusing women has increased over the past 25 years. Tailoring programs to women has meant moving away from traditional male dominated, confrontational models of treatment towards modalities that address the different needs of women (Brown, Sanchez, Zweben & Aly, 1996). The paradigm is shifting from treatment of an individual client, to a mother-child/family-centered orientation in which treatment is coordinated around the family unit, and where prevention and early intervention are stressed. Variations in services may include programs where mothers and children live together in a treatment setting, are educated regarding child development, and where treatment schedules are modified to meet the needs of mothers with small children.

Substance abuse prevention efforts have targeted youth as a vulnerable at-risk population for substance abuse. SAMHSA's Center for Substance Abuse Prevention has identified effective, model programs created to assist youth in overcoming exposure to risk factors through the enhancement of protective factors. (See SAMHSA's web page: www.samhsa.gov/centers/ csap/modelprograms.) Programs like The Strengthening Families Program coordinated by the University of Utah's Health Promotion and Education Department provide interventions including parent training, social and life skills training, and family practice sessions. SAMHSA is creating opportunities for the application and evaluation of these types of intervention strategies to families living with mental illness. For example, the SAMHSA-funded Women with Co-Occurring Disorders and Histories of Violence multi-site initiative will provide empirical evidence of the effectiveness of interventions for families derived from the substance abuse prevention and treatment arena, and applied to the special population of women coping with mental illness, substance abuse, and trauma, and their children.

SUMMARY: There is considerable overlap between the population of parents with substance abuse and those with mental illness, given the high rates of co-occurring substance abuse and mental health disorders and the prevalence of parenting in both groups. However, knowledge gained in the substance abuse treatment community regarding mother-child/family-centered prevention and treatment does not seem to have been applied widely in the mental health arena, though SAMHSA is providing opportunities for the application and evaluation of intervention strategies derived from this arena to other special population, e.g., women with co-occurring disorders and histories of violence, and their children. Few programs have been developed specifically to meet the needs of parents with co-occurring disorders and their families.

RECOMMENDATIONS: Substance abuse and mental health systems and providers need to coordinate and integrate services, and work together with other systems of care (i.e., child welfare, rehabilitation) to create a continuum of care for parents and families. Substance abuse treatment programs that have been modified to meet the needs of women, and to coordinate and provide services for families can serve as models to program development efforts for parents with mental illness and their families.

Women and Trauma/Violence
Twenty to thirty percent of women in the United States have experienced some form of sexual or physical abuse during their lifetime (Mowbray, Oyserman, Saunders & Rueda-Riedle, 1998). Abuse is usually not an episodic occurrence, but rather part of a history of violence and trauma. Violence against women is a growing public health crisis (Alexander & Muenzenmaier, 1998). Victims of violence often struggle with related issues including poverty, homelessness, substance abuse and mental illness. Women victims of violence are at increased risk for depression, post-traumatic stress disorder and suicide attempts (Bassuk, Melick & Browne, 1998; Miller & Finnerty, 1996). Children are affected by witnessing violence in their home or neighborhood environments (Osofsky, 1995; Overstreet & Braun, 2000; Schwab-Stone et al., 1995). Having childhood experiences of trauma or abuse can contribute to women's difficulties in current relationships and parenting (Melnick, 1999; Nicholson, 1998 presentation).

Women receiving mental health care are rarely asked about a history of sexual or physical abuse (Levin & Blanch, 1998). When professionals ignore these experiences, women may discount the devastating impact of violence on their lives. They may not receive needed treatment with respect to trauma or the impact of trauma on parenting. Women with a history of trauma have multiple service needs that are best met through integrated and coordinated systems of care, and a holistic approach to treatment that embraces the related issues of mental health and substance use. Recovery can only be achieved through attention to the interconnectedness of the issues that face women, and through the creation of a multidisciplinary, comprehensive treatment model including, for women with children, the issues of family.

SUMMARY: Prevalence of trauma among women and parents with mental illness is likely to be high. Trauma histories are likely to impact overall functioning and parenting in particular. Mental health providers do not always assess trauma histories sufficiently, consider the impact of trauma on parenting, or provide appropriate treatment. The issues of parents who are trauma survivors are disregarded by providers in service planning for adults and in treatment relationships with their children.

RECOMMENDATIONS: Epidemiological studies are needed to describe the extent to which women trauma survivors are parents and, likewise, the extent to which parents are trauma survivors. Descriptive studies are needed to explore the ways in which trauma experiences are related to aspects of parenting among adults with mental illness. Mental health providers need to be aware of the impact of trauma in women's lives, and the need to address this in trauma-sensitive treatment approaches, particularly with respect to the parenting role. Children's service providers must be sensitive to the needs and respectful of the preferences of all parents and, in particular, the unique issues of those who are trauma survivors.

HIV/AIDS
Women are the fastest growing cohort for HIV infection in the United States, accounting for 23% of adult cases from July 1998 to June 1999 (Centers for Disease Control, 1999). As a result, AIDS is one of the leading causes of death in 25 to 44 year old women (Centers for Disease Control, 2000). Women living with serious mental illness are at increased risk for HIV infection, with seroprevalence rates from 4% to 23%, exceeding the infection rates of the general population (Carey, Weinhardt & Carey, 1995). This increased risk results from a constellation of factors that may include limited access to health care, poverty, limited educational opportunities, poor living conditions (often in high crime areas), exposure to physical and sexual abuse, and possible cognitive or emotional limitations that may compromise an individual's ability to understand and observe safe sex practices (Aruffo, Coverdale, Chacko & Dworkin, 1990; Weinhardt, Carey & Carey, 1998).

While the number of women affected by HIV/AIDS is large, there is little research, policy or programming devoted to the concerns faced by HIV-infected women who are parents. Research on drug treatment effectiveness has centered on men while policies towards pregnant women with AIDS stress prevention and often encourage women not to get pregnant. Treatment has primarily focused on the health of the fetus and not the mother (Corea, 1992).

Research has shown it is crucial to address multiple needs when targeting high-risk populations to reduce HIV/AIDS risk behaviors (Kalichman, Adair, Somlai & Weir, 1995). For pregnant and parenting women, this most often includes their children. Just as mental illness is not the central theme for many parenting women, neither is AIDS/HIV infection. These illnesses are part of the larger challenges many women face, like compromised health, economic circumstances, and social supports, while at the same time trying to parent their children as best they can. While women describe their children as the focal point of their lives, most HIV/AIDS programs provide few services, e.g., family-centered care management, that would overcome parenting-related to obstacles to appropriate and regular medical care (Williams, 1990). Common themes revealed through interviews with HIV-positive mothers were: (1) fear of disclosing their HIV status to their children; (2) fear of infecting their children through casual contact, even though most women understood this was not how HIV/AIDS was transmitted; and (3) the impact of the illness on their ability to raise their children, both in the present and in the future, when they may not be available to care for their children themselves. (Faithfull, 1997).

In order to meet the multiple needs of HIV/AIDS mothers, specialized programs need to be developed that address the pragmatic issues of living with HIV/AIDS (i.e., health care, housing, child care) in coordination with social and emotional supports to help mothers through a time of loss, mourning, and isolation. While mothers with mental illness dealing with HIV/AIDS present further unique circumstances, the basic premise remains the same.

SUMMARY: Women represent the fastest growing cohort for HIV infection in the U.S. Women with mental illness are at increased risk for HIV infection. Research, policy and program initiatives have traditionally ignored the multiple needs of HIV-infected mothers with mental illness and their children. Lack of coordination around women's health concerns results in the inability to provide appropriate services and supports.

RECOMMENDATIONS: Given that women with mental illness disproportionately experience problems of substance abuse, violence, trauma, and HIV/AIDS, it is crucial to address these concerns through comprehensive, multidisciplinary treatment approaches. Integrated health, mental health, substance abuse, and trauma services that address the physical and mental health and well-being of women and their families would benefit women and children living with multiple vulnerabilities.

Criminal Justice: Women in Prison and Jail
Three out of every four incarcerated women have children (Johnston, 1991; Stanton, 1980), accounting for approximately 145,000 children in the United States with a mother in jail or prison (Gillard & Beck, 1998; Johnston, 1995). As the incarcerated population continues to increase by approximately 6.5% a year (Gillard & Beck), the number of children with mothers in prison will also increase. Seventy percent of these children live with grandparents or other relatives (Johnston).

The prevalence of mental illness in the female jail population is significantly higher than that of the general population. Over 80% of a randomly selected, stratified sample of 1271 female jail detainees in Chicago met criteria for one or more lifetime psychiatric disorders, the most common being substance use or dependence and posttraumatic stress disorder (Teplin, Abram & McClelland, 1996). Major depressive episode and dysthymia are extremely prevalent. Teplin and collagues indicate the predominance of PTSD among female detainees, most likely related to the high rates of violent victimization, suggest and important, largely unmet aspect of their mental health needs.

Incarcerated women, specifically mothers with mental health issues, are underserved. The majority of services and programs offered in prison are based on models originally designed to serve men. As a result, many of the unique concerns and needs of women and mothers remain unaddressed. For example, few prisons and jails facilitate or support on-going relationships between mothers and their children. The role of motherhood for incarcerated women does not end upon entry into jail or prison. In fact, key informants report that motherhood remains the central focus of the lives of many incarcerated women. This creates a prime opportunity and, possibly, motivation for rehabilitation.

Innovative programs focus on the needs of incarcerated women as mothers. In Washington, DC, the Family Literacy Project brings children and women prisoners together to read books. This provides story time for the children, improves the literacy rates of the women, and gives families a chance to participate in normalizing activities. The Neil J. Houston House, in Boston, Massachusetts, is a pre-release program where women in the criminal justice system with substance abuse problems live with their young children. In this setting, motherhood is central to treatment. The Maryland Correctional Institution for Women (MCIW) hosts a program run by the Girl Scouts of Maryland and the National Institute of Justice. Troop meetings are held twice monthly at the MCIW where mothers and daughters discuss issues of relationships, substance abuse, teenage pregnancy and self-esteem. The Bedford Hills Correctional Facility in New York operates a nursery program with approximately 25 beds. Babies born to female inmates live with their mothers on the nursery floor of the prison hospital for up to one year. The children of women with more time to serve are placed with relatives or in foster care (Gabel & Johnston, 1995).

While mental health services are acknowledged as an integral piece of treatment for incarcerated women (Teplin et al., 1996), one key informant noted that admission into these special programs for mothers may not be available to women with psychiatric diagnoses or receiving mental health services. Programs for incarcerated mothers must therefore be creative in their approaches to meeting the needs of women with mental illness. In addition, key informants indicate that mothers with mental illness in the criminal justice system experience and have to cope with the issues of loss and frustration common to all mothers separated from their children.

Similar to the research on outcomes for children whose parents have mental illness, most of the research on children of prisoners has focused on their problems, though researchers have found that all have areas of strength (Johnston, 1995). Three factors were identified by Johnston as consistent themes for children of incarcerated parents-parent-child separation, enduring traumatic stress, and an inadequate quality of care (Johnston, 1992). In addition, stigma and shame are important issues for children of prisoners (Gabel & Johnston, 1995). Many children of incarcerated parents enter the child welfare system for foster care services, as placement with relatives or friends may not be possible (Norman, 1995). The Child Welfare League of America has focused on the needs of these children and families. (See for example, the special issue of the Child Welfare Journal on Children with Parents in Prison, September/October 1998, and Wright & Seymour, 2000.)

Phillips and Harm (2001), authors of a National Association for Family Based Services report on the needs of children of incarcerated mothers, recommend that children need a safe, stable environment free from further trauma, crisis intervention and case management services, and support groups. Their mothers benefit from interventions targeting their understanding of their rights and responsibilities as parents, and that address substance abuse, domestic violence, and child abuse/neglect; parent support programs and parent skills classes are recommended. The authors conclude that employment, housing and financial assistance are components of a comprehensive approach to the reunification of mothers and children following incarceration.

SUMMARY: The majority of women incarcerated in the U.S. are mothers; many have mental health issues and service needs. Mothers in jails and prisons often are not supported in their role as parent. Separation from one's children is a tremendous loss for a woman. According to key informants, the ability to parent one's children is a central focus and rehabilitation goal for many incarcerated mothers. Comprehensive programs for incarcerated mothers and their children may not be available, particularly to women with known mental health problems. As with other populations described in this section, the issues and needs of incarcerated parents and their children have considerable overlap with those of parents living with mental illness and their families.

RECOMMENDATIONS: Prisons and jails should adopt a preventive and/or rehabilitative approach with pregnant and parenting women, and address the special issues and needs of mothers with mental illness and their children. Failure to tap into the rehabilitative opportunities of serving time does a disservice to women, their families and society at large, since few women remain incarcerated their entire lives. Women can benefit from parenting education and skills development while incarcerated. Strategies developed for working with mothers in the criminal justice system and their children may be applicable to working with mothers with mental illness and their families in the mental health system, given the overlap in populations and similarity of circumstances and needs, particularly for those parents hospitalized in psychiatric facilities. While the focus of this work has been on mothers, the issues and needs of incarcerated men and those with mental illness who are fathers should not be ignored.

Psychosocial Rehabilitation
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 (Cook et al., 1996).

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 (Anthony, Cohen & Farkas, 1990; Mueser, Drake & Bond, 1997).

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 (Baron, 1998; Collins, Bybee & Mowbray, 1998; Mueser et al., 1997). 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 (Nicholson & Blanch, 1994). 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 (Budd & Holdsworth, 1996; Grisso, 1988). Concerns have been raised regarding the use of parent evaluations in child protection decisions (Budd, Poindexter, Felix, & Naik-Polan, 2001). 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 (Davis & Barua, 1995). Decisions with great consequence for adults and children are made with little basis in science, and are subject to much individual discretion (Hester, 1992; also see, generally, Daubert v. Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579, 1993). Comprehensive multidisciplinary evaluation team models are recommended, but may be difficult to fund or staff (Budd et al., 2001; Jacobsen, Miller & Kirkwood, 1997).

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.

Table of Contents | Previous | Next