Supporting families of parents with mental illness in general practice

In general practice, key information often lies “in the shadows” of the presenting problem. For the parent with a mental illness, a “wide-angle lens” approach is required. This considers the parenting role of the patient and assists the practitioner and the family to understand the interplay between the parent’s mental health problems and family life. A useful tool is a family genogram, which includes stepchildren, deceased children, miscarriages, previous parent partners, and close family supports.11 This will take several visits and evolves as the patient feels more secure and the therapeutic relationship develops. For example, Rob later discloses that his stepson Mark lives with Rob and Anne on alternate weekends and is also affected by Anne’s depression.

Exploring the familiy’s dynamics and wider social supports highlights the needs and resources of family members. The GP can facilitate the inclusion of a relative or a trusted person outside the family to provide emotional and practical support. For example, is there someone else who can kick a footy with Adam? Can a local playgroup help Anne and Jade find some special time together? The GP can also assist by encouraging parents to consider community supports. Examples include playgroups, council youth programs, parenting support groups, and community mental health support services.

Better outcomes for the child begin with assisting parents to understand the impact of their mental health on their parenting, and the impact of parenting on their mental health.12 Parents need support to explore these links, and it is important that acceptance of mental health problems by an individual is linked with a positive sense of self or it can result in internalised stigma (“I’m so useless; I’m even ruining my kid’s life!”). The goal is for parents to recognise their illness, and its potential impact on others, without feeling disempowered, blamed or worthless. Encouraging parents to seek support and information for their health (and for their parenting if necessary) not only assists the child but also strengthens the parent’s motivation for recovery.13 A recent study found that as a parent’s understanding of mental illness develops, feelings of guilt and shame decrease and children report less anxiety.14 Therefore, the GP can:

• provide information about the patient’s condition and how it may impact on parenting, while exploring ways parents can minimise the impact of their illness on their family life;

• discuss the strengths and resources that the patient already has;

• highlight that the challenges of parenting are common and any illness can exacerbate these. Drawing links between the challenges faced by parents with other illnesses (eg, severe arthritis) can “normalise” parents’ concerns. This can neutralise parental self-blame and promote a more objective approach; and

• maintain awareness that the GP does not hold all the answers and that ideas developed by the patient and the family themselves can be the most powerful and long-lasting.

For example, in case study 2, Tom and Diane learnt to recognise the influence of Tom’s depression on Adam’s behaviour and were praised for seeking help. Insight and affirmation were combined with strategies for strengthening Tom’s key role in Adam’s life, and Tom started kicking a footy with Adam in the evenings again. Later, when Tom’s illness prevented him from identifying further small positive steps, the focus shifted to managing Tom’s depression while ensuring that Diane and Adam accessed their own supports during this time.

Exploring mental health issues in the perinatal period, and providing quality advice and care if problems are detected, can reap long-term benefits for children and their families.15 In addition, assessing any potential risk to the child of neglect or abuse, and arranging for supports to be put in place, is a useful prevention strategy. In extreme circumstances (eg, a parent with a long-term psychotic illness, who is not responding well to medication), arrangements may need to be made for the child to be temporarily removed from the immediate care of the parent. In such circumstances, don’t be afraid to ask pregnant mothers what they want for their child when it is born. The parent with insight is often relieved and grateful to know that a safety net can be put in place in the event that they become very unwell.

Family psychoeducational interventions and appropriate family communication about parental mental illness can reduce psychological symptoms and improve family functioning.16-19

GPs can draw on their inherent skills as an educator, counsellor and carer to support all family members to communicate about parental mental illness. When more focused or specialist intervention may be required, GPs can also refer a patient and his or her family to specialist mental health services and educational supports such as Children of Parents with a Mental Illness (http://www.copmi.net.au).

With practice, and some knowledge of child development, GPs can facilitate discussions about parental illness with children. For example, 5-year-old Jade mentions “Mum’s doona days”. Asking her what happens on these days and how she feels allows gentle exploration of her understanding and experience of her mother’s illness: “It’s sad all around”. Fourteen-year-old Adam described it as “all too lonely”, and found fact sheets and video-blogs from reputable websites such as beyondblue (http://www.beyondblue.org.au) and itsallright (http://www.itsallright.org) helpful: “It’s good to know I’m not alone”.

GPs can encourage parents to talk with their child about parental mental illness and highlight opportunities for communication and reflection that are present in everyday activities, such as storytelling and play. Storybooks, such as the classic Dr Suess’ My many colored days, can assist the parent and child to explore and reflect on emotions together in the comforting and nurturing zone of storytime. When promoting the use of books and play, it is important that the GP highlights that each child is different, so parents can confidently be guided by their knowledge of their own child’s language and favourite ways of interacting. Some examples GPs can share with parents include:

Does the child love to talk things over? Jade and Anne used to have a “special chat” every afternoon before Elise was born. When Anne re-established this activity, Jade’s behaviour improved dramatically. A teenage child might prefer talking to his or her parent in the car or on a walk around the block for “one-on-one” time.

Does the child prefer sitting quietly and drawing? Ask the child to draw a picture of his or her most and least favourite things and reflect on these pictures with their parent. The older child may prefer to write a story about another child in a similar situation or start a diary.

Is the child a little superhero who loves saving the day? Talk about how even superheroes get sick and time helps them recover. For an older active child, drawing on sporting figures the child identifies with can be invaluable.