Reprinted from "Parenting" issue of Visions Journal, 2004, 2 (2), p. 32
I am a child and family therapist working at a community mental health team in Vancouver. At any given time, at least one quarter of my caseload of approximately 30 children has a parent who has, or has had, a serious mental illness. These children present with clinical difficulties including depression, anxiety and serious behaviour problems, as well as other concerns.
Recently, I met with a little boy whose father was in the hospital with a major depression. The child had been referred because he was not sleeping well, not eating, avoiding school, and told his family doctor that he sometimes didn’t want to live. The doctor had referred him to our service.
Since his father attended our clinic, I wondered why we hadn’t already been aware of this boy and hadn’t offered him help before he developed so many symptoms. Why had he not been directly referred by his father, mother, or adult therapist? I can only speculate that our system’s preoccupation with helping his father as an individual had somehow not facilitated a family approach that could have provided earlier help to this child. I also wondered whether his mother and father understood the benefit of involving a child therapist to work with the family.
The boy began to improve after the first session. After three sessions – where we talked about ‘yucky feelings,’ created some expressive art, talked about his own strengths and the strengths in his family, and read a booklet together from the BC Schizophrenia Society about parents with gloomy moods – he was doing much better (sleeping again, eating, going to school, etc.). I also had an opportunity to talk to his mother about the stress she had been under and provide some emotional support.
Parents who have a mental disorder or who suffered from one in the past need to understand that their children are at an increased risk to develop both 'internalizing disorders’ such as depression and anxiety and ‘externalizing disorders’ such as behaviour problems. They will likely need professional help if their children do develop these symptoms and will also benefit from support in developing parenting approaches to lower the risk to their children. Their children also have a higher than average risk of developing illnesses such as schizophrenia and bipolar illness, and parents need to be aware that early identification and treatment of these diseases is important.
What are some of the dynamics that lead to problems? One is ‘parentification,’ a situation where the child takes a stance that he or she does not need help and resists accepting help from parents or other adult figures. In fact, the child feels that he or she is an adult, and actually in charge of their parent – often leading to power struggles, bossiness and unpopularity with peers, and/or a great burden of responsibility for the child to carry. This child often feels that he or she can have control by manipulating others and by not accepting anything for themselves. These children may become ‘too good’ at dealing with disturbed behaviour in others and are at risk of making poor relationship choices in their teens and not getting the love they deserve in adult intimate relationships.
Other children become dependent and ‘enmeshed’ with the ill parent to the extent that they are afraid to sleep by themselves, refuse to go to school if they are worried about their parents’ health, and may develop symptoms such as stomachaches or headaches.
Both groups of children can become very angry – raging, either by striking out at others or by self-harm – because they have not learned to regulate their emotions. Sometimes their parents have been either distracted by their own needs or too reactive to contain the child’s negative emotions at a crucial stage in the child’s development. There are, however, ways that these problems can be worked on and corrected.
When I talk about these issues with parents, I always promote the idea of advance planning or ‘Ulysses Agreements.’ There are many advantages of making a plan for the care of the child in case of relapse.
What is advance planning
A basic model of advance planning should include the following elements when drawing up a plan:
Details: lists the date, the people named in the agreement and phone numbers; also contains a list of people to inform about the agreement.
Statement of Purpose: the purpose of the agreement is to provide a clear set of guidelines to be taken by members of the individual’s support team if the person exhibits illness symptoms that interfere with her or his ability to provide good care for the child.
My symptoms: lists symptoms that the person making the agreement would like others to notice and respond to, and describes the most helpful way to respond.
Plan of action: records how the writer would like to deal with the issue of confidentiality and attaches signed consents if desired. Even with consent, no more information than is necessary for the implementation of the agreement should be shared.
Record of writer’s wishes for support services: advance plans can include planning for therapy and support for the child, even if an alternate care arrangement is not needed.
Record of writer’s wishes for care of the child: including any information about special needs such as allergies, sleeping routines, etc.
Cancellation: describes the manner in which the agreement can be cancelled. It is wise if cancellation requires a period of time and a set of steps.
Periodic review: describes the manner in which the agreement will be reviewed (e.g., annually.)
This model is not a legal agreement, but an expression of the parent’s concerns and intentions made when they were not acutely ill. Parents do have the right to cancel, even if they are acutely ill, but at least expressing their honest desires may help people understand that the illness is causing the problem, and allow for reconciliation afterwards. The Ministry of Children and Family Development is not under an obligation to follow these agreements, but will respect the parent’s wishes unless there is a concern about the safety of the child (including concerns about emotional health).
I have found that often there is less motivation to develop these agreements when there are two parents, but it is still a worthwhile project. Working on the advance plan may open up a therapeutic conversation centred on the needs of the children, which can have many positive effects.
What does advance planning do?
By considering a ‘worst case scenario,’ it is like disaster planning. It promotes putting energy into solutions, breaks down denial, and allows parents to express care and concern for their children.
By inviting others to participate in the advance plan, it opens up opportunity for honest communication and builds a support network for the family. It also allows plans to be made for specific needs, such as interpreters and other community helpers.
Another benefit is that it focuses on the illness and responses to the illness, and avoids blaming the person living with the illness. In addition, it helps to break down stigma about mental illness, which flourishes in silence. Finally, it allows the people named in the advance plan to learn about the illness and to express their love and support to the parent and child by agreeing to participate in the plan.
What problems can advance planning address?
Below is a list of problems that the advance planning process can address:
The problem of fear. It allows parents to discuss and plan for how to manage fears in advance (such as the fear of involving child protection services).
The problem of lack of insight. When ill, parents may deny that a problem exists. This includes not recognizing when one is becoming unwell, the ongoing effects of the illness, and/or the seriousness of the illness; not following treatment; not protecting kids or, for example, involving kids in the psychosis; and allowing kids to be in dangerous situations or around unpredictable people.
The problem of confidentiality. Someone (i.e., principal, counsellor or teacher) at the child’s school or daycare needs to know about serious problems that affect the child in order to provide needed support to the child during a crisis. Through this process, parents can agree to create a supportive network for their child, rather than leaving it to the discretion of mental health workers during a crisis.
The problem of lack of inter-agency protocols and appropriate family and community supports. Through the process of developing advance plans, the whole community can get better at supporting families with parents who have a mental disorder.
Does it work?
Advance plans do not always work out the way they are intended, often because of the way the illness actually plays out during a relapse. Even with planning, the parent may rescind consents or refuse intervention. Family members and others may still intervene inappropriately.
However, despite these drawbacks, I have seen this type of planning help people develop much needed support networks, with great benefit to children.
About the Author
Sharon is a child and family therapist working with Vancouver Community Mental Health Services