Introduction

In recent decades deinstitutionalization of persons with mental illness has contributed to normalization of their lifestyle. Consequently, a greater number of people suffering from mental illness now form relationships and have children (Devlin and O’Brien 1999; Manning and Gregoire 2008). Families in which parents have a mental illness are at increased risk of experiencing multiple problems such as poverty and social isolation. These parents have been identified as parents who face many challenges, exacerbated by the lack of services relating to the needs affecting their parenting (Park et al. 2006).

Parenting stress has been identified as one of the most common daily concerns faced by parents with mental illness (Kahng et al. 2008). Mowbray et al. (2004) found that, regardless of their specific diagnosis or demographic characteristics, mothers with mental illness may experience high levels of parenting stress. Many of the sources of parenting stress raised by parents with mental illness are generic to all parents, while others are specific to the situation of parents living with mental illness (Nicholson et al. 1998). Issues that parents with mental illness have identified as specific to their situation include dealing with the stigma of mental illness, which limits their ability to freely discuss areas of concern, managing day-to-day parenting whilst managing mental illness, the side effects of medications that could impair their ability to parent (Savidou et al. 2003) and social isolation (Nicholson et al. 1998). Parents with mental illness are vulnerable to multiple stressors besides the risk associated directly with the mental illness: they are at high risk of living in poverty and have very low employment rates.

Despite the difficulties in parenting in the shadow of mental illness and, consequently, the risk that their difficulties may create for their children, this population is often defined as an invisible one. Professionals in the mental health field may neglect to pay attention to the parenting roles and parenting needs of this population (Maybery and Reupert 2009). However, it has been asserted that parents who have a mental illness can be helped to parent their children effectively in spite of the difficulties they may have with their children. Due to the deficit in services for parents with mental illness and knowledge about how this population could be helped with issues related to their parenting functions, a study was conducted in Israel to identify the parenting-related concerns raised in the group and the therapeutic factors in the group process that provided a response to these concerns.

A Group for Parents with Mental Illness

The group modality has the potential to provide valuable help for parents with mental illness with their parenting-related concerns and difficulties. The unique contribution of participation in group therapy has been conceptualized by Yalom (1995), Yalom and Leszcz (2005) who indicate eleven therapeutic factors that they believe can significantly help facilitate change within individuals participating in groups. There are factors in the group process thought to effect beneficially the participants’ growth (e.g., interpersonal learning, group cohesiveness, universality). The occurrence and impact of these therapeutic factors vary within a group and from group to group (Erdman 2009). Examining the occurrence of these factors in a group for parents with mental illness can illuminate which kind of therapeutic factors are being manifested in a group for this population, as well as the ways in which such a modality could be helpful for them.

The group that has been the subject of the evaluation presented in this manuscript has been an ongoing group conducted once a week in an adult day treatment center of a psychiatric hospital in Israel. All the participants were parents with mental illness who received services either in the adult day treatment mental health center or other therapeutic services in the community that referred them to the group. The group was a joint project of two services. The facilitators of the group were a staff member from the adult day treatment center and a staff member from a treatment center for families and children. The collaboration between the staff members was based on integrating the views and expertise of a professional who specialized in treating adults with mental illness and a professional who specialized in the provision of family and child mental health services. It should be noted that although the emphasis in this paper is on evaluating the therapeutic factors that primarily stem from interactions among group members, a significant aspect of the group’s process was the facilitators’ direct help to group members. The approach of the group facilitators included: psycho-educational interventions aimed at enabling group members to process the meaning of the difficulties they encounter in their parenting experiences; supportive and consultative interventions aimed at helping group members overcome barriers in their interactions with helping systems and attempts to seek help from these systems with issues related to their children; and interventions aimed at facilitating the helping relationships among group members.

Method

This research is a process oriented evaluation of an ongoing therapy group conducted once a week during a period of 21 months for parents with mental illness and was designed to examine the following questions: (1) What the parenting related concerns are that parents with mental illness raised in the group, and, (2) What the therapeutic factors in the group process are that helped participants with their concerns. There were two instruments utilized to examine these questions. The first one was a questionnaire given once a week to the group facilitators who reported on the main concerns raised by the group members in each of the group sessions and the main group related therapeutic factors which were manifested in the process of providing a response to the participants’ concerns. In the questionnaire, the two facilitators were asked to record the dilemmas, needs, conflicts and difficulties raised by group members, and to indicate how the group members helped each other with their concerns. The second instrument was a questionnaire consisting of open-ended questions given to the participants once every 3 weeks to learn about the parenting related concerns that they hoped to resolve through their participation in the group. Participants were asked to list the positive things they hoped would happen in their parenting as a result of their participation in the group, and whether there was anything that they were afraid would happen during their participation in the group.

A qualitative method of data analysis, using grounded theory as the guiding framework was utilized to analyze the data collected from the implementation of the two instruments. The themes and categories were not determined before the data collecting stage, but were identified as the data were analyzed (Janesick 1994). The data were classified and analyzed by two persons who had not been involved in the data collection. The analysis was reviewed by the two group facilitators for its appropriateness to the actual process occurring in the group. This research was approved by the Human Subject Committee of a psychiatric hospital and by the Human Subject Committee of the university where one of the researchers is employed. Participants gave written informed consent for study participation.

Results

Background of the Participants

Thirty-five persons participated in the group during the 21 months that the evaluation was conducted. Nineteen of them were men and 16 were women. The mean age of the participants was 43 years and the mean number of their children was 2.7 (range of 1–9). Almost 50 % of the participants (n = 16) were divorced or separated, and 40 % of participants (n = 14) had not been living with their children or had experienced periods of separation from their children. All the participants were diagnosed with mental illness that justified receiving treatment either in the day treatment center of the psychiatric hospital for an average period of 3 months or in other therapeutic services in the community. The diagnoses of the participants were: Mood disorders that included bipolar and depressive disorders (49 %), personality disorders (23 %), schizophrenia (14 %) and adjustment disorders (14 %). During their participation in the group, most of the participants had a need to receive intensive daily help for several months in a psychiatric day treatment center due to a mental health crisis. However, all of them lived in the community and functioned independently after discharge from the day treatment center.

The Group Process

The analyses relate to the group process as documented by the group facilitators and indicated by the group members about the issues that were of concern to the parents during their participation in the group, the power of the group, and their parenting related hopes and fears.

Overcoming Difficulties to Connect to the Children and Maintain Relationships with Them

A central theme in the group was the parents’ relationship with their children when the children were not living with them. They raised issues relating to difficulties and dilemmas they experienced, because of a lack of knowledge, about how to connect and maintain relationships with their children, and how to renew relationships and reconnect with the children after a long term separation, inconsistent connection with them, or reluctance of the child to meet with the parent. They related to insecurity in their role as parents because they may not live with the child and fulfill the parenting roles on a daily basis, situations in which they encounter difficulties of coping with their mental illness during the time they spend with the child, and situations in which they encounter difficulties to meet with the child due to economic difficulties of the parent.

The therapeutic factor of imparting information (Yalom and Leszcz 2005) was manifested in the group process through the suggestions given by the group members to each other about how to connect or maintain contact with their children despite barriers they may experience. For example, they provided suggestions to each other about how to increase involvement in their children’s lives. They encouraged each other to meet with his/her children during the holidays and gave suggestions for activities with the children during these meetings, as well as about how to cope with difficulties in establishing a connection with the children (e.g., being persistent about calling the child).

Group members also provided the participants with encouragement about finding ways to meet with the child despite resistance they may encounter. This was especially significant considering the insecurity of some of the participants in their role as parents. For example: Group members supported a father’s effort to travel to visit his daughter and helped him understand the significance of phone calls in maintaining the connection with her.

Beyond providing information and encouragement, participants also expressed empathy and identification with group members’ insecurity in their role as parents, with situations in which parents expressed fear of losing custody of the child, and with the difficulties parents expressed about connecting with their child. The group served as a place to express the pain of the separation from the children and lack of connection with them. Via group participation parents felt, in a way, the universalism of their difficulties in their relationship with their children. The therapeutic factor of universalism provided them the feeling that they are not alone in their difficulties (Yalom and Leszcz 2005). As one of the participants pointed out, “Everyone has his own difficulties and, therefore, I feel good about sharing my own difficulties.”

The group also served as a place to report progress in overcoming barriers to reconnection with their children, and as a source that instilled hope in their ability to advance this objective. Via discussion in the group, parents revealed common interests they have with the child as well as positive changes, rewarding and happy moments with the children, including those related by a mother who spoke very emotionally about the fact that her children bought her a ticket for a vacation.

Speaking with the Child About the Mental Illness

Communication with the children about the mental illness was also a central theme in the group. The group served as a place where parents could raise, discuss and receive advice regarding their dilemmas about whether or not to tell the child about the mental illness and how to explain about the mental health difficulties they experience. For example, participants discussed how to adjust the depth of the explanation to a two and a half year old child as opposed to an 8 year old child; whether to include the medical diagnosis in the explanations given to the child; and how to explain to a child the constraints the parent has which hinder his/her participation in activities with him/her (e.g., not being able to do something because of depression). Group members gave each other examples of possible explanations appropriate to the child’s age. Such interactions provided group members an opportunity to develop socializing techniques, a therapeutic factor that provided group members the opportunity to replace inadequate or maladaptive cognition and behaviors with more effective ways of conceptualizing their world and interacting in it (Yalom and Leszcz 2005). For example, a mother who had been hospitalized for depression had been thinking about how to explain to her 6 year old child what mental illness is. In the group, she raised her dilemma about how a child can comprehend the meaning of the phrase ‘mental illness,’ an abstract and complicated phrase, as the reason that she ‘disappeared’ when she was hospitalized. Group members helped her find alternative explanations, such as, instead of using the phrase ‘mental illness,’ tell the child that there are occasions when the mother is weak and sad and she needs help. Finding more suitable expressions to explain their mental illness could help parents reduce the barriers they encounter with their children.

Socializing techniques were also implemented in the case of a father who expressed a dilemma about whether or not to tell his daughter that the reason for his infrequent visits was his depression. On one hand, concealing the mental illness may project a stronger image of him as a parent, and on the other hand being open with the child may lead to receiving support from her. However, it may create an emotional burden for her. Parents learned in the group that what could really be perceived as a sign of weakness is their inability to speak with the children about significant issues bothering them, such as the mental illness.

The group also served as a source for interpersonal learning. This therapeutic factor involves developing an understanding of how one is perceived by others, and realizing how one can improve interpersonal functioning (Yalom and Leszcz 2005). It was manifested in the way in which group members helped parents who shared too much information with the child, including inappropriate information. For example, there was a mother who shared with her children details about the symptoms of the illness, what medications she takes, and even her thoughts about committing suicide. The group members and facilitators advised her about more appropriate boundaries in her communication with her children.

Another function of the group was to provide an opportunity for catharsis, a therapeutic factor that involves an expression of emotion that is in some way liberating or enlightening for the individual (Yalom and Leszcz 2005). The group served as a source of support with the pain and sadness accompanying the process of the parents’ telling the children about the mental illness, as well as a place where parents could share the outcomes of telling the child about the mental illness.

Improving Parenting Skills and Developing the Role of a Parent

The group also served as a safe place where parents could raise issues pertaining to ways to strengthen their identity as parents and improve parenting skills. They addressed difficulties they experience in their parenting, including difficulties stemming from low self-esteem as parents (e.g., “there are times when I feel that I’m the worst parent in the world”) and insecurity in their identity as parents due to their mental illness (“how can I tell my child what to do when I’m not functioning well due to the mental illness?”).

Boundary and discipline were most prominent among the issues presented by group members, and they gave each other advice about how to change inappropriate parenting behaviors. They wanted to know how to create appropriate physical and emotional space between a parent and a child and how to cope with behavioral difficulties or lack of ability to discipline the child. For example, a parent who threatened a child that he will hit him, understood through the discussion in group that this was not an appropriate way to relate to the child.

The group also served as a source of encouragement and support in the parents’ attempts to be more authoritarian with their children and as a place where parents reported success in changes in their parenting practices. For example: there were parents who reported feeling competent to deal with problems they had not been able to cope with in the past: a father who had been increasingly able to enjoy the child’s music.

Parents related to the power of speaking about the children on their self-perception as parents: “The fact that I’m in the group and speak about the children gives me the feeling that I’m more involved in my child’s life.” They reported the empowering effect of discussing in the group their relationship with their child: “I feel encouraged, I moved from being passive to being active in my relationship with my child.” They repeatedly attributed the changes to the group: “This change is thanks to the group, I receive a lot of support and empathy that helps me overcome my difficulties.”

Hopes and Fears Regarding Parenting

Other concerns for which they expected to receive help through their participation in the group related to what they hope will happen and what they are afraid will happen in their parental functioning. Their hopes focused on their ability to maintain a good relationship with their child. For example: “I hope to meet my child more often.” They also related to expectations regarding the quality of the relationships: “I hope to develop good mutual relationships with the child”; “to receive their love” and to their hope that the children will accept them as parents despite their difficulties: “that the children will always accept me, even when I’m in a difficult state of mind.” Parents emphasized their love and concern for their children’s well-being despite mistakes they may have made.

They especially related to their hope to be a good parent, “to be a good mother,” “to take responsibility for my child,” “to have patience for my children,” “not to behave as a monster to my children.” Another kind of hope noted was that they could take a meaningful part in the daily life of the children: “to get involved in the daily difficulties experienced by my children and the development and changes in their lives.” Parents also related to their hope to have the ability to simply function as a parent, “I would like to feel I’m a father despite everything.”

Parents addressed their fears regarding their relationship with their children. These focused on the possibility that they will stop functioning as good parents: “I will stop functioning as a mother.” Another kind of fear was that their relationship with their children will be disrupted, “fear that I’ll lose control,” and that they will stop being involved in their children’s lives: “that I’ll lose the friendship with my children,” “that they will not respect me and will distance themselves from me.” The lists of hopes and fears demonstrated the centrality of the children and the parenting role in the participants’ lives and corresponded to the issues raised and documented by the group’ facilitators.

In summary, the main therapeutic factors in the group processes that were helpful to the concerns raised by the participants were the following:

  1. 1.

    For difficulties and dilemmas about how to maintain their relationships with their children when they were not living with them: (a) Imparting information via suggestions about how to connect with and maintain relationships with their children; (b) Encouragement to connect with the child and empathy with the pain stemming from failures to do so; (c) Universalism, learning from the examples of group members that parents with mental illness share common difficulties; (d) Possibility of reporting progress regarding attempts to connect with the child.

  2. 2.

    Speaking with the child about the mental illness: (a) Advice about what and how to tell the child about the mental illness; (b) Learning from group members socializing techniques about how to communicate appropriately with children about their mental illness; (c) Providing an opportunity for catharsis because of the emotions related to telling the child about the illness.

  3. 3.

    Difficulties in parenting functions: (a) Providing a safe place to discuss difficulties; (b) Advice about how to develop skills to overcome difficulties in parenting functioning; (c) Receiving encouragement and support about improving and changing their parenting skills.

Discussion

The findings illuminate the value of the group modality for parents with mental illness. It provided a context in which parents could examine ways to handle the difficulties and complexities of fulfilling their parenting roles via therapeutic factors such as imparting information, interpersonal learning and socialization techniques (Yalom and Leszcz 2005) at the same time as they cope with their mental illness. Through the group process parents could learn not only the universality of their concerns, that other parents with mental illness share difficulties similar to theirs, but the opportunities they had in the group to reflect upon the significance of the parenting role in their lives and to normalize their parenting roles may contribute to their recovery process by helping them develop and expand their parental identity and awareness of having roles and capabilities beyond the mental illness (Slade 2009).

The group provided a format in which parents could discuss their dilemmas and concerns about whether, what, and how to tell their child about the mental illness. This has been shown to be of great concern for parents with mental illness, who have not had contexts in which they could discuss them. The group helped parents overcome the barriers affecting their directness and honesty when speaking to the children. This differs from the indirect explanations that parents with mental illness often gave their children.

Parents with mental illness could bring up their difficulties and parenting deficits without the fears they may have of possible negative ramifications when speaking about their vulnerabilities to professionals in mental health and social services. This is especially significant for this population considering the limited resources of help and the barriers the parents may encounter if they do try to contact the child and adolescent mental health services (Maitra and Jolley 2000). Shulman (1984) defined this process in groups as a dialectical process where group members can expose and risk their tentative ideas and use the group as a sounding board, a safe place for their views to be challenged and possibly changed.

The findings show that even though in mental health and social welfare services there is often a separation between parenting related issues and treating the mental health issues of parents (Tunnard 2004), these issues are interrelated and cannot, and should not, be treated separately. Because of the significance parents attributed to their relationships with their children, their desire to improve their relationships and the changes group members reported in their relationships with their children as a result of their participation in the group, this modality of treatment can have a preventative function. It could contribute to reducing the risk to the children by providing the parents with a chance to overcome their parenting difficulties.

The evaluation of the group process presented in this study is limited to the experience in one treatment service for persons with mental illness in the community. Research should also be conducted on the implementation of the group modality in other therapeutic services for adult persons with mental illness, such as in hospitals. In addition, other methods of data collection of the group processes should be implemented, such as recording and transcribing the contents of the group sessions in order to overcome potential bias if the data are being documented primarily by the group facilitators as in the present study. Since one of the main concerns raised by participants related to difficulties in functioning as a parent, it would be valuable, in addition to helping parents with these concerns in the group, to conduct parenting skills classes and examine their impact on the parent–child relationships.