Parenthood and severe mental illness: relationships with recovery.

Although parenting is an important life domain for many people, there is little research about the parenting experience for those with a severe mental illness and even less on the role of parenting in recovery. This is a surprising oversight, given high rates of parenthood are typically found in community-based samples. For example, the National Comorbidity Survey found that rates of parenthood for those with severe mental illness are similar to or higher than those without a mental illness, with 67.2% versus 62.4% for women and 75.5% versus 52.9% for men (Nicholson, Biebel, Katz-Leavy, & Williams, 2002). Although some have found lower rates of parenthood ranging from 36–38% (Gewurtz, Krupa, Eastabrook, & Horgan, 2004; Hearle, Plant, Jenner, Barkla, & McGrath, 1999), others have found rates comparable to those in the National Comorbidity Study (Joseph, Joshi, Lewin, & Abrams, 1999). In an empirical investigation of the recovery concept and its principal components, Resnick, Fontana, Lehman, and Rosenheck (2005) identified four domains that serve as the building blocks to recovery: feeling satisfied with one’s quality of life, having hope and optimism for the future, feeling empowered in one’s life, and having knowledge about mental health and possible treatments. Given the key role of parenthood for many, it is likely that parenting is related to a number of these recovery-related concepts. First, with respect to the recovery concept of feeling satisfied with quality of life, evidence indicates parenting is an important and rewarding experience for parents with severe mental illness. In several qualitative studies, mothers with severe mental illness have described being a parent as fulfilling, noting that parenthood gives their lives meaning (Diaz-Caneja & Johnson, 2004; Mowbray, Oyserman, Bybee, MacFarlane, & Rueda-Riedle, 2001; Mowbray, Oyserman, & Ross, 1995; Sands, 1995; Sands, Koppelman, & Solomon, 2004). Second, with respect to feeling hope and optimism, mothers have expressed a variety of hopes for their children, such as a life free of abuse and the ability to graduate high school (Sands, 1995). Given the positive aspects of parenting and the hopes typically held for children, it may be that those with severe mental illness who are parents are more hopeful than non-parents. Hope has been repeatedly recognized as a concept integral to recovery (Jacobson & Greenley, 2001; Noordsy et al., 2002; Resnick et al., 2005), and may play a key role in how parents with severe mental illness view the future for themselves and their children. The two other domains of recovery, empowerment and having knowledge about one’s illness, may also be related to parenting. Closely related to empowerment, autonomy (i.e., the desire to be informed and involved in treatment decisions) has been identified as a key concept in the recovery movement (Onken, Dumont, Ridgway, Dornan, & Ralph, 2002), but autonomy preferences in psychiatric decision-making have not been well studied, and have not yet been examined in parents with severe mental illness. A further related area of interest is consumer activation in psychiatric treatment. Activation in treatment is a function of one’s knowledge, confidence, and skills in managing illness (Hibbard, Stockard, Mahoney, & Tusler, 2004). Although this would seem a central concept to recovery, there is limited research available regarding activation in mental health treatment (Druss et al., 2010; Green et al., 2010; Kukla, Salyers, & Lysaker, 2013; Salyers, Matthias, et al., 2009), and no study has investigated the relationship between parenthood and patient activation. Although research is limited, we hypothesized higher levels of both preferences for autonomy and activation in treatment among parents with severe mental illness, due to these consumers’ desire to make the best choices for both themselves and their children. Despite the potentially recovery-promoting role of parenthood, parenting needs are often not addressed in mental health services for adults with severe mental illness, and consumers report numerous unmet parenting needs (Brunette & Dean, 2002; Nicholson & Biebel, 2002; Nicholson, Biebel, Hinden, Henry, & Stier, 2001; White, McGrew, & Salyers, 2013). Relationships with treatment providers are important for these consumers, considering the often chronic nature of severe mental illness, the close relationships many consumers maintain with health care professionals, and the effects of these relationships on several aspects of recovery, including consumers’ feelings of empowerment, their perceived knowledge, and hope for the future. Although little research on physician trust for people with severe mental illness exists, studies of other populations have shown that patients’ level of trust in their physicians is related to how often patients seek care, the type of information they are willing to reveal, adherence to treatment plans, level of engagement in making treatment decisions, satisfaction with care, and treatment follow-up (Bova, Fennie, Watrous, Dieckhaus, & Williams, 2006; Hall et al., 2002; Kraetschmer, Sharpe, Urowitz, & Deber, 2004; Safran et al., 1998). Issues of trust in physician and subsequent disclosure may be particularly salient to parents with severe mental illness. These parents report feeling mental health clinicians do not address this important aspect of their lives (Ackerson, 2003; Nicholson et al., 2001), which may impact their perceived quality of care and their engagement in services. Fear of loss of custody is a recurring theme in the literature, with parents reporting reticence to bring up mental health concerns or parenting problems with their physicians (Bassett, Lampe, & Lloyd, 1999; Nicholson, 1996). Indeed, parents who experienced custody loss of their children also reported a general loss of trust in mental health professionals (Diaz-Caneja & Johnson, 2004), indicating that being a parent may impact consumers’ level of trust in their psychiatric care providers. Given these findings, we hypothesized that parents would have less trust in their physicians than non-parents. Although research on parenthood’s effects on recovery-related concepts is limited, some research has separately investigated parenting issues for mothers and fathers with severe mental illness. Mothers with severe mental illness spend considerable amounts of time engaging in childrearing activities, so environmental supports and specific knowledge or skills training are needed (Brunette & Dean, 2002; Mowbray et al., 2001). Though more mothers than fathers with severe mental illness are primary caregivers of children (Jones, Macias, Gold, Barreira, & Fisher, 2008), a substantial number of men report living with their children and appear to have an impact on the wellbeing and developmental outcomes of these children (Fletcher et al., 2012). One study (N = 806) that compared mothers and fathers with severe mental illness to non-parents with severe mental illness found 46% of the women were mothers and 21% of the men were fathers (Nicholson, Nason, Calabresi, & Yando, 1999). Fathers were significantly older than non-fathers, more likely to be racial/ethnic minorities, and more likely to have ever been married. Compared to mothers, fathers were significantly younger, but did not differ in current/past marital status or other background characteristics. Interestingly, most fathers were no longer married, highlighting the potential need for assistance with custody and/or visitation. To date, no research of which we are aware has investigated differences between mothers and fathers with severe mental illness regarding recovery-related areas of functioning, such as autonomy, hope, activation, or trust in provider. Given the lack of parental support typically provided in mental health services, a better understanding of how mothers and fathers view these different areas may be important when developing future interventions and services. Exploratory evidence in this area will increase available information about the intricacies of parenthood in consumers with severe mental illness. Considering the lack of research examining associations between parenthood and recovery-related constructs in people with severe mental illness, the current study aims to provide preliminary evidence of how these concepts are related in a sample of individuals receiving services at a community mental health center. Using baseline data from a longitudinal study of shared decision-making in treatment of severe mental illness, we hypothesized that parenthood would be positively associated with measures of hope, activation in treatment, autonomy preferences, and perceptions of recovery. We hypothesized that parenthood would be negatively associated with trust in physicians. We also explored potential differences between mothers and fathers in order to yield helpful information about how to tailor services to meet the needs of parents with severe mental illness.