Even though all professionals stressed that the parents loved their children, the interviews became focused on the negative aspects of being a parent with psychosis. These negative descriptions were characterised by difficulties providing security and predictability, commonly attributed to symptoms of paranoia and lacking the ability to organize family life, and difficulties focusing on the child’s needs, commonly attributed to the parent being occupied with their own emotions. These difficulties were described as resulting in the child not being given emotional support and as making the child take on a greater responsibility than they should need to; sometimes forcing the child to take on the role of the parent.
The results will be discussed according to the difficulties described by professionals, and the support needed to address these difficulties and assist parents with psychosis to develop more positive parenting abilities.
Parents’ Fear and Lack of Positive Role Models
The professionals described paranoia as one of the most influential symptoms on parenting, however not the only one. Symptoms of paranoia was described as making the parent vigilant, suspicious, and stressed. Paranoid ideations was also described as potentially making the parent overreact to internal and external cues of potential danger; creating a parent who was unable to provide security. When suspicion was directed towards the child, parents were described as being both frightened and sometimes even frightening, especially for younger children who rely upon the parent’s reactions to external stimuli. Oftentimes, the service users was also described as lacking insight in how such parenting behaviour affected their children. Parents who lacked understanding of their symptoms, were described as less able to protect their children from their symptoms. The importance of parents’ cognitive capacity, such as insight, was stressed as important when parents explained their illness experiences to their child.
Paranoia is, by definition, a problem of interpersonal reference, with excessive attention to the behaviours and feelings of others. Moreover, a lack of social identification or belongingness underlies paranoia (Freeman et al.
2008), and a recent large-scale study shows that enhancing social identification reduces its symptoms (McIntyre et al.
2017). Considering the interpersonal roots of paranoia, it is not surprising that this symptom has implications for caregiving. In line with previous research that suggests that social identification might reduce paranoia (McIntyre et al.
2017), parenting interventions could be conducted in groups. There are also studies showing that the service users themselves request groups focused on both general parenting and parenting while experiencing psychosis (Alakus et al.
2007). Such groups might provide a safe social context in which the participants can share their experiences and fears. Parenting interventions could also offer participants the opportunity to reflect upon and share their experiences of how interpersonal insecurity influences their caregiving and parenting; it could also help parents identify situations in which their fear restricts their child’s need to explore.
The professionals emphasized that many parents had grown up in dysfunctional families with violence and abuse, and they attributed some parents’ inability to comfort and show emotional warmth to their family of origin. Such experiences were also described as having left the parents without role models. These accounts are supported by several studies showing associations between psychosis and childhood adversities such as sexual, physical, and emotional abuse (e.g., Varese et al.
2012; Bonoldi et al.
2013). Qualitative studies also report descriptions of service users’ own parents as abusive and uncaring and their family of origin’s emotional climate as cold, meagre, and silent (e.g., Strand and Tidefors
2012).
Role models are an important aspect of caregiving and parenting. It is well-known that parenting and behaviours are based on experience (i.e., influenced by experiences with the parents own parents). It is also known that individuals with experiences of abuse in their family of origin struggle with more parenting anxiety, stress, and insecurity than others (Hugill et al.
2017). An important part of interventions for parents with negative experiences in their family of origin is to help parents choose positive role models to emulate in their parenting. Focusing on how parents’ experiences of caregiving in their family of origin influences their own parenting could also be a way to help them reflect upon and identify parental strategies based on more positive role models. An experience-based intervention focused on the link between past and present relations, instead of the link between the illness and the shortcomings of the parents, might be perceived as less stigmatizing and attract service users to take part in family interventions; a task that numerous studies has proven to be difficult (Schrank et al.
2015).
Parents’ Difficulties in Recognizing and Responding to the Child’s Needs and Feelings
The professionals described parents’ difficulties in setting aside their own anxiety and needs to focus on the child’s needs for comfort and emotional guidance, and the emotional climate in such families was described as meagre. Some parents were described as too anxious or as unable to show affection towards their children, while other parents were described as having difficulties regulating their own emotions which could lead to intense expressions of particularly fear and aggression. Parents’ lack of recognition about how their own emotional state might affect their children was described as an obstacle to the parents’ ability to guide and support the child and some children were described as being forced to focus on their parent’s emotions, and as sometimes taking on the role of the parent.
The ability to make sense of and adequately respond to both their own and others’ behaviours, needs, and feelings is referred to as mentalization (Fonagy and Target
2006). Problems in mentalization are common in people with schizophrenia (Sprong et al.
2007). A concept related to mentalization, but used to describe parents’ ability to understand the child’s mental states, is parental reflective functioning (RF). A recent review of studies in non-clinical samples shows that higher parental RF is associated with adequate caregiving, while low parental RF is found in mothers whose children suffer from anxiety, impairment in emotion regulation, and externalizing behaviours (Camoirano
2017). There is also scientific support for an association between a history of abuse and neglect and lower parental RF (Berthelot et al.
2015). Clinical interventions designed to improve parental RF could usefully be offered to parents with psychosis for several reasons: the strong associations between schizophrenia and low levels of mentalization (Schiffman et al.
2004; Sprong et al.
2007); parents’ difficulties in recognizing and coping with the child’s needs and emotions (Healy et al.
2016); and the negative affect of neglect and abuse on parental RF (Berthelot et al.
2015).
Some parents were described as relying on their children when they themselves were distressed, anxious, or in need of company. Moreover, because of some parents’ inability to organize and plan family life, many professionals described children who had to take on a greater responsibility than a child should need to. Children taking on parental responsibilities to an extent that exceeds the developmental norms in the culture is sometimes referred as role reversal (e.g., Boszormenyi-Nagy and Spark
1973). Responsibilities can include giving the parent instrumental help (e.g., cooking, cleaning, looking after younger siblings) and emotional help (e.g., advice, comfort, reassurance, company). A more recent, child-focused perspective is the concept of “young carers”, i.e., children and youths who provide practical and/or emotional support to a family member who has any type of illness (Dearden and Becker
1997). The professionals in this study confirmed that some children provided both instrumental and emotional help to their ill parent. Instrumental help was most commonly described as a response to the parent lacking motivation, and emotional help was described as related to parental anxiety.
From a relational perspective (Boszormenyi-Nagy and Spark
1973), role reversal stems from the parent’s unsatisfied needs to be parented and cared for. From an attachment perspective (Bowlby
1980), the parent is seen as unable or unwilling to give the child the protection, support, and the care it needs presumably because the parent’s own needs for reassurance and protection remain unmet. Based on our findings, a combination of both theories could enrich the understanding of role reversal because these parents appear to have both unsatisfied needs of being cared for and extensive needs for reassurance and protection because of their anxiety and fear.
In individual therapy, role reversal is often treated by enhancing the parent’s own sense of security (Byng-Hall
2002). Parenting interventions could more appropriately focus on exploring and providing information about children’s emotional needs and the possible consequences if their needs are unmet. Research using the concept of young carers also shows the importance of incorporating the family system and providing instrumental family support to unburden the child (Wahl et al.
2017). More research focusing on the underlying mechanisms of role reversal in this group of parents is necessary. A better understanding could also address role reversal in parenting interventions for service users with psychosis.
Clinical Implications
In addition to psychological and psychopharmacological treatments, the results indicate that interventions targeting parenting in patients with psychosis could preferably be held in groups and include elements of (1) linking childhood experiences of caregiving to their own parenting, (2) creating positive role models to use as a basis for parenting, (3) developing parental RF, (4) educating parents about their children’s emotional needs and attachment signals, (5) and identifying situations in which symptoms hinder satisfactory parenting. The psycho-educative elements found in existing family interventions, such as BFI and FI, are also an important aspect in supporting parents with psychosis and their children.
Limitations and Areas of Further Studies
It is important to stress that these findings are based on the professionals’ perceptions and should not be assumed to accurately describe any actual family situation. However, the professionals’ had extensive experience in working with these patients and their families and through their role as child coordinators at the service units. It is also important to emphasize that although the interview questions were open-ended and focused on parenting abilities, the professionals mainly discussed the parents’ difficulties and problems. Therefore, it is important to note that other studies have shown greater heterogeneity in the parenting quality of parents with psychosis (i.e. Campbell et al.
2018). It is also possible that mental health professionals are less reluctant to report adversities than the parents themselves. Another possibility is that mental health professionals are more focused on attending to difficulties and needs. However, the discrepancies between the perceptions of mental health professionals and those of the parents themselves require further studies.