Working with Adults with Mental Illness

Vol. 4, No. 2
May 1999

Working with Adults with Mental Illness

While most parents with mental illness do not abuse their children, and while the parents of most abused children are not mentally ill (National Clearinghouse, 1994) child welfare workers often encounter adults with mental illness. Making the appropriate referrals is extremely important in such cases.

However, once you have assisted an adult with mental illness in reaching people who can address his or her needs, you will probably still be interacting with this person, perhaps very closely. You may be required to share some decision-making regarding his or her children.

The children who are your clients are part of a larger system that includes their close family members (Anderson & Carter, 1990). The mental illness of an adult in the household can have a powerful effect on children (Schlosberg & Kagan, 1977). You and your clients may face difficult situations that require you to interpret, understand, and react to an adult's actions when those actions may be confusing, or even frightening, due to the adult's illness.

It is therefore important to have some basic knowledge and skills regarding adult mental disorders. Mental illness is distinct from developmental disabilities, such as autism or mental retardation (DSM-IV, 1994). While these ailments are also risk factors for abuse (Cantwell, 1980; Frude, 1989), and may introduce new difficulties into your work, we will limit our discussion here to working with adults with mental illness.

Mental illnesses are extremely varied. Some can be quite serious and debilitating; others may be so mild as to go unnoticed, even by mental health professionals. Since your client is the child, you aren't there to treat the adult's illness. Attempting to do so would be inappropriate (Reamer, 1995; Hepworth & Larsen, 1997). However, increasing your knowledge can prepare you to work more effectively with adults who are mentally ill.

Learn about Mental Illness. Consider reading further about mental illness, especially any particular illness that affects the adults with whom you work. You can discuss these issues with mental health professionals, remembering to respect the confidentiality of the adult in question. Learning about mental illness can help you work with a mentally ill adult and avoid stigmatizing mental illness.

Avoid Stigmatizing Mental Illness. Adults with mental illness have long been the victims of severe social stigmas, based on the assumption was that they had a moral deficiency (Lin, 1995). Today, professionals recognize that most individuals with mental illness suffer from a biological imbalance of the chemicals in the brain; this is why many medications are effective in treating mental illness (Kramer, 1993). Other contributing factors to mental illness include medical conditions, stress, trauma, severe childhood abuse, prolonged substance abuse, exposure to toxins, and genetically inherited traits (DSM-IV, 1994; Rauch, Sarno, & Simpson, 1991).

Balance Flexibility with Firmness. You can expect that parents with mental illness will be difficult to work with sometimes. Depending on their particular condition, they may be unwilling to accept responsibility, unable to remember agreements, untrustworthy, difficult to understand, inconsistent with discipline, poor at keeping appointments, and unpredictable emotionally (Schlosberg & Kagan, 1977). They may generally demonstrate confusing behavior.

On the other hand, adults with mental illness, like everyone else, are responsible for their actions. Missed appointments, lying, and dangerous behavior cannot be accepted. Communication with your supervisor—or with the appropriate mental health professionals on your agency's staff—is the surest way to avoid problems (Shulman, 1995).

Good Supervision Is Critical. In dealing with adults with mental illness it is crucial that you receive consistent supervision from someone with the professional training and experience to assist you. This person will be able to help you make the distinction between appropriate flexibility with a mentally ill adult and inappropriate collusion with that adult. In other words, a certain amount of tolerance may be necessary to get your job done.

Confidentiality. Confidentiality may also become an issue with adults with mental illness. Keep in mind that only information essential to the treatment of your client and the safety of staff, clients, and other individuals need be shared with other professionals, and only people legally allowed to have such information should get it (Reamer, 1995; Hepworth & Larsen, 1997). Working with adults with mental illness may provide some interesting stories, but these individuals are entitled to privacy, and breaking confidentiality is a serious offense. Speak with your supervisor about any questions you may have about this.

Monitor Your Level of Involvement. It may be appropriate to offer some limited assistance to adults with mental illness in the family of your juvenile client. Letting the adult know about services in the community or handing the adult a bus schedule can be a very useful way of relieving family stress without taking on the role of "rescuer" (Schlosberg & Kagan, 1977). But the safety of the child(ren) is your primary concern, and becoming over-involved with the parents can be detrimental.

There is also the risk of forming an adversarial or confrontational relationship, and this, too, can be harmful to your work. Countertransference (emotional reactions on your part that affect your work) is a serious risk. It is easy to become frustrated or angry with an adult's inappropriate behavior. It is also understandable that you feel sympathy for people with mental illness and that you may want to help them (Lin, 1995). But allowing these reactions to interfere with your primary role would be unprofessional and detrimental to your work (Schlosberg & Kagan, 1977; Hepworth & Larsen, 1997).

Focus on Strengths. It would be quite easy to regard people with mental illnesses as crises waiting to happen and, focusing on their problems, to view their situations as hopeless. But rather than focusing on the problems, you will meet with more success and reduce stress and stigmatization if you seek to find the particular strengths of each individual, family, and system.

So, while a parent may have a severe mental illness, such as depression, that person may also be extremely intelligent. Or, while a parent may be suffering from substance abuse disorder, he or she may express great love for his or her children, and be willing to receive assistance with parenting skills.

No matter how severe the mental illness, there are always strengths to be built upon. Take the time to learn about your clients' families and their strengths; they will appreciate it, and everyone will benefit (Hepworth & Larsen, 1997).

Treat Everyone as a Person First. It is best to approach adults with mental illness in the same way you would relate to anyone—with respect, with appropriate boundaries, and with an understanding of that person's role in the life and care of your client. Therefore, discussing parenting strategies with a parent with mental illness, just as you would with another parent, is appropriate.

Granted, this may be more difficult due to the parent's illness. While many with mental illness are extremely intelligent and motivated, a severe mental illness can present communication barriers, and may hinder the parent's ability to implement parenting strategies. Yet each parent will have strengths that can serve as a starting point. The ability to read, or a sincere motivation to learn, can be the perfect starting point for a struggling parent.

Certain mental illnesses may make it difficult or impossible for a parent to care for children effectively and consistently (DSM-IV, 1994). A mental health professional, such as a psychiatrist, psychologist, or clinical social worker, may recognize these situations; he or she may also be able to treat parents with therapy or drugs so that they are again able to function as a parent.

The training given to a child welfare worker may enable you to judge that a particular parent is being neglectful due to mental illness. However, when judging whether the parent with mental illness is capable of proper care, the same criteria should be used as with any other parent—that is, your careful, informed observation. Simply being mentally ill does not disqualify someone from being a parent. In fact, many adults with mental illness benefit from the structured approach to parenting offered by child welfare workers. In the end, people with mental illness are just human—no more, no less.

To learn more about working with adults with mental illness, see "Working with Adults with Mental Illness: Practice Tips".

References

Anderson, R. & Carter, I. (1990). Human behavior in the social environment: A social systems approach. New York: Aldine DeGruyter.

Cantwell, H. B. (1980). Child neglect. In C. H. Kempe & R. E. Helfer (Eds.), The Battered Child (pp. 183-197). Chicago: University of Chicago Press.

Diagnostic and statistical manual of mental disorders, fourth edition. (1994). Washington, D.C.: American Psychiatric Association.

Frude (1989). The physical abuse of children. In K. Howells & C. Hollin (Eds.), Clinical Approaches to Violence (pp. 155-181). New York: John Wiley & Sons.

Hepworth, D. H. & Larsen, J. (1997). Direct social work practice: Theory and skills. Pacific Grove, California: Brookes Cole Publishing Company

Herring, R. (1992). Unpublished doctoral dissertation. Howard University, Washington D.C.

Kramer, P. (1993). Listening to Prozac. New York: Penguin Books.

Lin, A. M. (1995). Mental health overview. In R. Edwards (Ed.), The Encyclopedia of Social Work. Washington, D.C.: National Association of Social Workers.

Munro, J. (1985). Counseling severely dysfunctional families of mentally and physically disabled persons. Clinical Social Work Journal, 13(1), 18-31.

National Clearinghouse on Child Abuse and Neglect Information. (1994). Child abuse and neglect fact sheet. Washington, D.C.: Author.

Polansky, N. A., Borgman, N. D., & DeSaix, C. (1972). Roots of utility. San Francisco: Jossey-Bass.

Rauch, J., Sarno, C., & Simpson, S. (1991). Screening for affective disorders. Families in Society. 72(10), 602-609.

Reamer, F. (1995). Ethics and values (including the National Association of Social Workers Code of Ethics). In R. Edwards (Ed.), The Encyclopedia of Social Work. Washington, D.C.: National Association of Social Workers.

Schlosberg, S., & Kagan, R. (1977). Practice strategies for engaging chronic multiproblem families. Social Casework, 58, 29-35.

Shulman, L. (1995). Supervision and consultation. In R. Edwards (Ed.), The Encyclopedia of Social Work. Washington, D.C.: National Association of Social Workers.