Mental illness: Where should family involvement begin and end when a parent needs treatment?

New study underlines need for a ‘think family’ policy in mental health treatment

One in five children in the Republic live in families with a parent who has a mental illness. Photograph: iStock

One in five children in the Republic live in families with a parent who has a mental illness. Photograph: iStock

 

A disconnect between the treatment of parents with mental illness and their home life ended in tragedy for the family of Andrew McGinley. But he isn’t the first bereaved parent on this island to ask, “why did nobody tell me?”

In May, after his wife Deirdre Morley was found not guilty by reason of insanity of murdering their three children at their Dublin home in 2020, McGinley said the medical evidence during the trial left him believing that communication between the professional services and his wife’s support circle could have prevented the deaths of Conor, Darragh and Carla.

Una Butler, whose two daughters, Zoe and Ella, were killed by her husband John in their Co Cork home before he took his own life in 2010, believes the same applied in her case. Patients should not be treated “as if they are living in isolation when they are not”, she said on RTÉ Radio One after the Morley verdict.

In Northern Ireland, John O’Neill has also spoken out about being excluded from any knowledge of the treatment of his estranged wife, Madeleine, for depression, during which she had told doctors she might harm their daughter. She went on to smother nine-year-old Lauren before taking her own life at their home in Carryduff, Co Down, in July 2005.

These are very extreme cases and Dr William Farrelly, president of the College of Psychiatrists of Ireland and a consultant psychiatrist, has argued in this newspaper – Family input should not be mandatory in treating mental illness – that while family involvement in the treatment of a loved one for mental illness should always be encouraged, it should not be made mandatory in law.

Although the incidence of children being killed by a parent with mental illness is relatively rare, suffering physical and mental health issues as a result of a parent’s mental illness are not. It’s why, in Norway for instance, it has been mandatory since 2010 that whenever a parent presents with a mental illness or addiction that the services check on the wellbeing of their family, to see what supports they might need.

In the Republic, one in five children, an estimated 280,000 people under the age of one, live in families with a parent who has a mental illness. That statistic alone highlights the need for a coherent “think family” policy across the adult and child mental health services.

Research shows that children of parents with mental illness are at greater risk of a range of adverse outcomes, including infant mortality, developmental delay, attachment problems, abuse and neglect, medical illness, and various mental disorders, such as depression, anxiety, substance abuse, and suicidal behaviour, as well as impairments to educational and occupational prospects. Both “nature” and “nurture” are at play in the inheritance of mental illness but lack of transparency and support contributes to the intergenerational cycle.

Family Talk

The Health Service Executive (HSE) is funding evaluation by Maynooth University of an intervention programme targeted at breaking this vicious circle. Called Family Talk, it’s a six- to eight-week course that includes sessions for parents, children and the entire family, which was developed in the US and is being piloted at 15 centres here. Its aims include helping children to understand their parent’s problems so they don’t blame themselves, and also to build resilience to developing their own mental health issues.

More than 80 per cent of parents with mental illness surveyed for the PRIMERA study after participating in Family Talk reported that it not only gave children a voice but also enhanced family understanding of, and communication around, mental illness. This had led to improved family interactions and warmer relationships.

According to preliminary findings of the study, conducted by the university’s Centre for Mental Health and Community Research, more than a third of parents with mental illness also indicated that their own mental health recovery was better. It boosted their parental and personal confidence.

Prof Sinead McGilloway and Christine Mulligan. Photograph: Dara Mac Donaill
Prof Sinead McGilloway and Christine Mulligan. Photograph: Dara Mac Donaill

Partners largely corroborated these benefits, also saying they appreciated having a forum in which they could voice, often for the first time, their experiences of partnering and co-parenting with somebody with mental illness.

Christine Mulligan, a doctoral student who interviewed almost 40 parents, partners and children for the study, says: “Our findings, to date, show that Family Talk provided families with their first opportunity to acknowledge the ‘elephant in the room’ in a safe environment. Parents felt better understood and the, often silent, concerns of partners and children were voiced and heard.

“By addressing the issue head on, partners and children were better equipped to support the unwell parent, but not at the cost of their own mental or physical health,” she adds.

Within two families, although children and partners reported considerable benefits of Family Talk, the parent with mental illness did not find it helpful. One mother said she “did not want to hear what others [in her family] were saying and blanked out” while a father was wary of discussing mental illness with his children.

Caroline, who has been suffering from mental health issues for the last five years and has been diagnosed with borderline personality disorder, was happy to be given the chance to participate in the research pilot of Family Talk. Her three teenagers were resistant at first but her husband was willing to try anything that might improve matters.

“It saved me and my family,” she tells The Irish Times, two years after they completed the programme. Having attempted suicide on “numerous” occasions, “it opened up my eyes, she says – not only to the negative impact her illness was having on her loved ones but also, on the positive side, their continuing love for her, despite her difficulties”.

‘Frank and honest’

Going into the sessions, “I felt like I was a complete failure of a mum. It was an everyday thought – why am I here? I am not doing anything for my kids and my husband. They are better off without me.”

It had been an overwhelming “I need out of here”, she explains, but she never thought about doing harm to anybody else. “It was a constant feeling of dread. How am I going to get through the day? What is the point?”

The children “were caring for mummy, I wasn’t caring for them. They were coming in with a cup of tea and a sandwich; they were putting on the washing. I literally done nothing in the house”.

Lack of transparency and support can contribute to the intergenerational cycle of mental illness. Photograph: iStock
Lack of transparency and support can contribute to the intergenerational cycle of mental illness. Photograph: iStock

She also withdrew from extended family and friends. “I wouldn’t take phone calls, wouldn’t text. I went up to 20 stone and I am not a tall person. I am down to 13 [stone] now.”

Once her children were convinced to take part in Family Talk, held at the local child and adolescent mental health service they had attended for their own anxiety issues, “they were frank and honest” during the sessions, says Caroline.  They talked, for instance, about being afraid of coming home from school, scared of what they would find, having discovered their mother collapsed in the house on previous occasions. “I found out that if they saw an ambulance they would flip. Simple things I wouldn’t even think about.

“It broke my heart to hear what they had to say but it gave me the push that I need to change this. Something needed to happen within myself and I don’t think I would have gone on to seek further treatment.

“As my husband used to say, it was like walking on egg shells around me. Although he has been hugely 100 per cent supportive of me through everything, it was a place for him to be able to talk as well.

“Sometimes he said he felt he was enabling me, from the point of view that I stayed in my bedroom for two years. He was running the house, working, doing all the kids – I wouldn’t leave. He’d bring me up a cup of tea in the morning instead of saying no, come downstairs and get it.”

She also heard her children talk about how much they missed her after she withdrew from life, no longer making the outdoor trips they had enjoyed with her or attending school events.

Safe place

Through the sessions she worked on a need-to-know basis: “I didn’t want to go too deep or reveal my most inner thoughts, in case it harmed them.” But she feels they got enough information from the questions they asked. “It totally changed the atmosphere in the house for the better. It’s a lot easier now for the kids if they feel they have something they want to come and talk about.”

Crucially, what she heard at Family Talk convinced her that she needed to come off all the medication she was on, initially for neurological issues that were diagnosed 15 years ago. The GP warned her it wouldn’t be easy and, indeed, it was a long process. However, enabled by weekly dialectical behaviour therapy that she started in October 2019, she is now a “completely different person”.

Children have told the Maynooth study that Family Talk gave them a safe space to disclose “hidden” concerns about a parent with mental illness. For the first time they were able to talk about problems it had caused in their own lives, such as being bullied in school, upset with fighting and tension at home, the burden of caring emotionally for other family members, depression, feelings of blame, sadness, and injustice/anger.

Several described how it had broken the silence, secrecy and stigma around mental illness within their families. As well as feeling that parents were now listening to them, they also experienced increased empathy and compassion for their parents whom they perceived as “trying their best” in challenging circumstances.

Prof Sinead McGilloway, principal investigator of the PRIMERA project, says she hopes this research will help to inform and embed family-focused approaches within child and adult mental health services in Ireland, “whilst also highlighting the urgent need to develop a national policy for engaging in appropriate, effective and timely ways with families experiencing parental mental illness”.

‘I was barely holding myself together’

Liam hadn’t realised how his “Mr Happy” persona wasn’t fooling his son until he heard the nine-year-old boy talk about being afraid for his father during a Family Talk session.

A very dysfunctional childhood, during which he suffered physical and emotional abuse at home and was sexually abused by a priest, has left Liam with mental health issues, including post-traumatic stress disorder. Sometimes he has night terrors and screams in his sleep.

“He was hearing this and saw how I was barely holding myself together some days,” says Liam, who has been the main parent raising the boy since separating from his wife. He had married a forceful but good woman, he says, and they had “a wonderful child” together. However, the breakdown of their marriage came out of the blue for him several years later.

“I was always the victim and it became very easy for her to take her stresses out on me,” he comments. “The [childhood] abuse has affected me my whole life.”

The period immediately after the separation was a rocky time for both father and son. Liam had been going to counselling for some years and when the centre that he attended suggested that he and his son try the Family Talk programme, he readily agreed. He was worried that, without professional help, he wouldn’t find the right words that his son needed, to cope with not only his own upset at his parents’ separation but also with observing his father’s emotional struggles.

The boy got great benefit from the session, he says. In a very comfortable way, they helped his son understand that sometimes his father would have bad days.

“A child can see through anything,” he points out. So he wanted his son to know that he didn’t need to worry, “that I am not going anywhere but I am dealing with stuff”.

“They helped me share with him, without telling him anything, to protect him from my suffering and my past.” Through the age-appropriate sharing, the boy could understand that his dad was okay and that they could both talk about their feelings.

However, listening to his son during the sessions was “extremely difficult” at times for Liam.

“There were a lot of things that broke my heart. One of them was the amount of worry he had for me, and I didn’t want him to ever worry about me because it was my job as a parent to worry about him.

“We have come so far since we did this; we talk so normally about stuff.” He believes his now 11-year-old son, who has regular overnight visits with his mother, is comfortable talking to him about whatever is in his head.

As for Liam himself, “I still have the hardship, I still have the nightmares but they don’t take over my life now. It is just something I live with, rather than live through”.

* Some names have been changed to protect privacy

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