Parenting experience of low-income single women with serious mental disorders, The

parenting experience of low-income single women with serious mental disorders, The

Sands, Roberta G

BEFORE DEINSTITUTIONALIZATION the reproductive lives of women with serious mental disorders were cloaked in mystery. Shackled by illness and the patient role, women were perceived as “almost genderless” (Test & Berlin, 1981, p. 136). Manifestations of sexuality in long-term hospitals were denied, ignored, or quietly managed, with resulting children placed in foster homes or put up for adoption (Apfel & Handel, 1993). Today, with the community as the primary locus for patient care, women’s sexuality has become a more obvious concern and the assumption of parenting responsibilities is a viable option (Apfel & Handel, 1993). Accordingly, we need to understand how women with mental illness experience parenthood.

This article describes an exploratory qualitative study of low-income single mothers with severe mental disorders who lived with their children and other mothers and children in supported housing. The study assumed that most of the problems of these women were similar to those faced by other poor single mothers but that “psychiatric illness compounded the effect of stress and strain experienced by these women” (Cohler & Musick, 1983, p. 159).

The research questions guiding this inquiry were as follows:

* What is it like to experience both motherhood and severe mental illness? How do these phenomena affect each other?

* What are the program demands (social, participatory, regulatory) experienced by chronically mentally ill mothers who reside with their children in a specialized community residential program?

* What are the psychosocial issues (wants and needs) of the mentally ill mothers?

* How do the experiences of mothers in the residential program differ from those of unafflicted mothers who live independently?

Previous Research

Research on chronically mentally ill mothers has focused primarily on the impact of maternal mental illness on children considered at risk of becoming mentally ill themselves (Gross, 1989). Much of this research has looked at the effect of the mother’s diagnoses of schizophrenia (Sameroff, Seifer, & Zax, 1982; Walker & Emory, 1983; Webster, 1992), bipolar or unipolar mood disorder (Conrad & Hammen, 1989; Hammen, Burge, Burney, Adrian, 1990; Klein, Depue, & Krauss, 1986; Lee & Gotlib, 1989; Radke-Yarrow, Nottelmann, Martinez, Fox, & Belmont, 1992; Weissman, Prusoff, Gammon, Merikangas, Leckman, & Kidd, 1984; Zahn-Waxler, Mayfield, Radke-Yarrow, McKnew, Cytryn, & Davenport, 1988), and panic disorder and agoraphobia (Biederman et al., 1990) on their offspring, Most of these studies identify psychiatric diagnoses or behavioral problems in progeny.

Many research studies longitudinally compare children of schizophrenic mothers with children whose mothers have other psychiatric disorders or who do not have psychiatric diagnoses (e.g., Erlenmeyer-Kimling & Cornblatt, 1987; Fish, 1987; Goodman, 1987; Jorgensen, Teasdale, Parnas, Schulsinger, Schusinger, & Mednick, 1987; Sameroff, Seifer, Zax, & Barocas, 1987; Weintraub, 1987) or compare children of severely mentally ill mothers with various diagnoses with those who are “well” (Stott, Musick, Clark, & Cohler, 1983). Generally, findings reveal that children of severely mentally ill mothers perform worse in cognitive, social, and attentional domains than do children of well mothers. Nevertheless, the degree of the mother’s disturbance, as well as her social competence, role-functioning ability, single-parent status, and the availability of an alternative caregiver, contribute to the outcomes (Goodman, 1987; Weintraub, 1987). Sameroff, Seifer, and Barocas (1983) found that social status was the best predictor of offspring cognitive development. Elsewhere, Sameroff et al. (1987) state that the severity of mental illness and social status are “general risk factors” that produce “general incompetencies in young children” and recommend that researchers more closely examine the social and familial environment of the child.

Researchers have looked at the child-rearing practices of mentally ill mothers. Goodman and Brumley (1990), for example, found that schizophrenic mothers had less affectional involvement and provided a less adequate child-rearing environment than did well mothers and that depressed mothers’ parenting behaviors varied in quality. Their results also showed that quality of parenting was a better predictor of children’s social and intellectual functioning than was diagnosis. Davenport, Zahn-Waxler, Adland, & Mayfield (1984) conducted a study in which they identified deficiencies in child-rearing practices in families in which one parent had bipolar disorder. Teti, Gelfand, and Pompa (1990) found that self-efficacy and the context of the mother’s environment were related to the competence displayed by depressed mothers in relation to their infants.

Other research has investigated the impact of the family’s social environment on the child. In a prospective study of offspring of mothers with schizophrenia who were later diagnosed with either schizophrenia or schizotypal disorder, Burman, Mednick, Machon, Parnas, and Schulsinger (1987) found a significant relationship between unsatisfactory relationships with parents and the development of schizophrenia in children In another study of 306 children of parents with mental illness, Stiffman, Jung, and Feldman (1986) found that environmental stressors, coping skills, and an interaction between the proportion of mentally ill members and activity competence predicted behavior problems in children. Elsewhere, the same authors (Stiffman, Jung, & Feldman, 1987-88) found that children who lived away from their biological parents in other living arrangements had fewer behavior problems than did those living with one or more biological parents. In their review of research on offspring of parents with schizophrenia, Walker and Emory (1983) concluded that genetic and environmental factors interact in the development of psychopathology in offspring. Similarly, Downey and Coyne’s (1990) integrative review on children of depressed parents reported that although such children are at risk for depression as well as various adjustment problems, contextual factors, such as marital discord, contribute to these problems.

In their studies of the welfare of at-risk children, researchers have focused little attention on the psychocial issues of mothers of these children and the impact of parenting on maternal mental health. Apfel and Handel (1993) highlight the reproductive losses suffered by women with severe mental illness. These losses are the result of voluntary and spontaneous abortions, stillbirths, and neonatal deaths as well as the placement of children in foster care, adoptive homes, or homes of relatives. In an ethnographic study of adults with dual diagnoses, Schwab, Clark, and Drake (1991) found that clients who had children placed a high value on parenthood. If they did not have custody but had visiting rights, they focused their lives on seeing their children. Those who lost their children at delivery through miscarriage or abortion or other means suffered with grief. The authors reported that these clients perceived the mental health system as being insensitive to their needs as parents.

Some research on mothers has focused on the postpartum period, which is considered a time of high risk of serious mental illness (Casiano & Hawkins, 1987). A follow-up study of 82 women who were treated for postpartum illness at Edinburgh Hospital between 1946 and 1971 found that the overall functioning of these women at follow-up was good for all but those with schizophrenia, who also had the highest probability of a recurrence (Davidson & Robertson, 1985). Another follow-up study of hospitalized mentally ill mothers in Sweden who were compared with an obstetric control group revealed that the mothers with psychiatric disorders had more complications with their pregnancies, a higher frequency of previous abortions, and lower attendance at the antenatal care clinics (Bagedahl-Strindlund, 1986). In order to address the needs of these at-risk mothers, some hospitals admitted postpartum mothers together with their infants to inpatient psychiatric units (Buis, Dennerstein, & Burrows, 1990; Crossling, Brooker, & McGrath, 1988; Stewart, 1989), whereas other programs offered parent training at a later period (Lieberman, 1985; Waldo, Roath, Levine, & Freedman, 1987).

Often, chronically mentally ill mothers are not served by programs attuned to their needs as both parents and adults with chronic mental illness. Mental health services do not always recognize that many of these women are sexually active (Jennings, Jennings, Sommer, & Burstein, 1987) yet minimally knowledgeable about birth control (McEvoy, Hatcher, Appelbautn, & Abernethy, 1983), although some offer family-planning services to this population (Coverdale, Aruffo, & Grunebaum, 1992). Residential programs for chronically mentally ill adults generally exclude children (Bachrach, 1988). In order to obtain housing, mothers may be forced to give up custody of their children. Although the research indicates that the quality of the parental relationship mitigates the effect of maternal mental illness on children, few efforts are made to provide support to mothers who have the capacity to raise their own children. Instead, these mothers are discouraged from having or raising their children (Torrey, 1988), or children are removed when the mothers are hospitalized or judged unfit.

The purpose of the present study was to gain an understanding of how these mothers experienced parenthood. It examined the women’s perceptions of themselves as mothers and persons with mental illness, their psychosocial issues, and their receptivity to programs addressing their needs.

Method

This qualitative study focused on parenthood among women participating in a community rehabilitation residential (CRR) program for mothers with severe and persistent mental disorders and their children. The program provided five supervised apartments in which two mothers and their preschool children shared each two-bedroom unit. Twenty-four-hour supervision by program staff who occupied an additional unit within the same apartment complex and a child-care center (called “social rehab”) for the program children located off the premises were also provided. Mothers with children in the center were required to assist at the center once a week.

The primary informants in this study were 10 single, low-income mothers with serious mental illness who lived in the CRR between 1991 and 1992. All of the mothers had at least one preschool child either living with them (n = 5) or in foster care or with a relative awaiting reunion while the mother became stabilized in the program (n = 5). Seven of the 10 women were African American, and three were white. Mothers’ ages were 21 to 37 (M = 27). Six mothers had at least a high school education, three mothers less than a high school education, and one mother’s education level was unknown. Six of the women had a diagnosis of schizophrenia, one schizotypal personality disorder, one major depression, one bipolar disorder, and one unknown. Seven had a history of substance abuse, and six had unstable or homeless living situations in the past.

Because poverty and single parenthood are associated with stress (Burden, 1986; McLanahan, 1983) but not necessarily with psychiatric disorder (Weissman, Leaf, & Bruce, 1987), low-income single mothers without severe psychiatric impairment were used as a comparison group. Eight single, low-income mothers of at least one preschool child who was attending a community daycare center participated in the study. This group is referred to as the “day-care mothers.” All of these women were African American, whose ages ranged from 22 to 40 (M = 29 years). Of these, five had at least a high school education, one had less than a high school education, and the education level of two was unknown. Six of these women were working, and two were in school. All of the day-care mothers lived independently with their children; three had other relatives living with them.

Multiple methods of data collection were used to gain a variety of perspectives on the same population and to cross-check findings (Denzin, 1989). The first method was participant observation by the researcher and her assistant at the “social rehab” program associated with the community rehabilitative residence. Each observer spent four to five hours a day on separate occasions for 11 days stretched over a period of four months observing the children, teachers, and “volunteer” mothers as they interacted with one another while the children participated in a structured program of activities (drawing, music, free play, lunch, etc.). At times, the observers assisted the teachers with the children.

The second method consisted of informal conversations with staff during the year in which data were gathered. Field notes were taken following all observations and conversations with program staff.

The third method consisted of interviews of the 18 mothers. Interviews were semistructured and open ended and addressed the following topics: life prior to having their first child, changes since becoming a mother, preparation for motherhood, daily life, the meaning of the child, program demands, experiences with mental health and child welfare systems, supports, stressors, and expectations for the future. Sixteen of these interviews were audiotaped and later transcribed. Because two of the mentally ill mothers consented to the interview but not to audiotaping, field notes were taken for them. Finally, the case records of eight of the CRR mothers who signed permission forms were read.

During the course of the study and after the interviews were transcribed, the researcher inductively developed themes and issues in keeping with the research questions that emerged from the data. Initially, an attempt was made to focus on the perspectives of the mentally ill mothers, leaving impressions of the staff and the official record in the background; for example, the case records were not read until the interviews were completed. At a later stage, data based on the perspectives of the mothers with chronic mental illness (transcripts of interviews) were compared with reports in the case records, notes from participant observations and conversations with staff, and interviews with the day-care mothers.

Findings

The findings of this study are described in the following sections. Where direct quotations at provided, M1 through M10 refer to mothers with severe mental disorders and M11 through M18 to the mothers with children in the community day-care center. Comparisons with the day-care mothers are woven into the three topics.

Experience of Motherhood and Mental Illness

Motherhood as a central life experience, One way or another, al the mentally ill mothers said that being a mother was central to their existence, that it gave meaning and focus to their lives. Those who had custody of their children expressed pleasure in having the children with them. When asked what the children meant to her, one mother said, “Near my life” (M8) and others said, “[My life is] more full, it’s more life to me” (M9) and “She makes me happy” (M10). Another mother, who was reunited with a child from whom she had been separated in the past, spoke of her appreciation of having the child with her now:

I missed a lot of things with her [when she was in foster care]. I now stay home, even if she is away, I stay home. See, right now I have to be there for her….It feels good ’cause I missed that when she was young, and I want to take care of her (M3).

Those who were still awaiting reunification with their children spoke with longing about becoming a “real family.” One spoke of coping with her upset feelings by drinking.

The day-care mothers were similar to the mentally ill mothers in the way their children had a central place in their lives. When asked what she wanted for herself in the future, one of the day-care mothers responded that she had not given much thought to the question “probably because my main concern is them and what they want out of life” (M12). Another woman talked about giving her children priority over a relationship with a man:

When we first started datin’, [he demanded] a lotta attention and I just told him that, you know, they come first…and if you don’t want to accept ’em, you know, then there ain’t no point for us to go on (M16).

One of the day-care mothers described vividly what she liked about being a mother:

I love having them around; I mean, I have very lovable kids when they wanna be and they love to kiss and hug, especially my son. Well, not hugs and kisses, but he comes and tell me about three times a day, “Mom, I love you” (M17).

In contrast with the mentally ill mothers, the day-care mothers expressed more ambivalence about being a parent. Several spoke about the loss of freedom that came with having children. Others mentioned that between their job or school and child rearing, they were under a great deal of stress. Many of these women admitted having difficulty disciplining the children. One mother said:

As soon as they wake up, it’s like, O.K., you pot to pet out, let’s go somewhere, get dressed, and let’s go somewhere. When they outside, they fine. When they confined, it’s like I’m going crazy. But I’m glad to be a mother. I tell everyone that everybody should have at least one child because it’s a nice experience. It has its good times and its bad times, but you know somebody’s always there for you. You know they’re always there (M15).

Struggles. Most of the mothers with mental disabilities struggled to maintain or obtain custody of their children. Several suffered the emotional trauma of having their infants removed from their homes by the child-welfare authorities because of neglect, incapacity, or substance abuse. Two of the mothers had their children placed in foster care voluntarily, although one felt that a member of the program staff talked her into it. Once the children were in placement, the mothers found it difficult to regain custody. The child-welfare agency required that they prove their fitness by having acceptable living quarters, controlling their psychiatric symptoms, and sticking to a visitation schedule. Several of the mothers expressed anger at and distrust of the child-welfare agency.

The pain over past losses of custody among these mothers should be seen in light of their family histories. Nine of the 10 women described experiences of family conflict or losses either in their families of origin or in their families of procreation. These included the hatchet murder of one parent by another, substance abuse by parents or a former husband, conflict with parents over the informant’s life-style, and being a foster child.

The day-care mothers, too, spoke of their struggles, but these focused primarily on economic survival, child management, and obtaining decent housing. One of these women, however, said she had entertained the idea of giving up a baby for adoption when she discovered that she was pregnant. Two women had contact with the city’s child-welfare agency, one in connection with the sexual molestation of her daughters and the other to obtain legal custody of a child of a relative for whom she was foster parent.

Mental illness and parenting. The mentally ill mothers did not describe themselves as mentally ill and preferred to speak about “problems,” “stress,” or “nerves.” Two women said that they thought that their mental health problems were caused by their having used drugs. Others said that their problems stemmed from worrying about the children or family conflict. One participant said that she was told that she had “dual diagnosis” but that she did not understand exactly what that was. When asked, the mothers revealed the number of times they were hospitalized and current participation in mental health services. Three women described what sounded like hallucinations and some spoke of having had a “nervous breakdown.” Several said that they now realize that it is important to remain on medication.

Stories about custody loss were vague, with few mothers attributing it to psychiatric problems. For example, one of the mothers said that someone at her boarding house reported to the child-welfare authorities that her child fell off the bed while she was busy doing chores and that this incident resulted in foster-care placement. It was not clear from her description whether she was simply neglectful or distracted by hallucinations. (Her lack of attentiveness continued to be noticed by staff and other mothers in the rehabilitation program.) Although the interviewer probed for the mentally ill mothers’ perceptions of the impact of their mental health problems on their parenting, few admitted to more than getting irritable or nervous around the children.

The day-care mothers were considerably more open to questions about their mental health and the relationship between their mental health and parenting. Most of these women complained about stress, which they attributed to raising children alone while working or going to school. One mother mentioned that she saw a psychiatrist briefly for depression; another said that she came close to having a “nervous breakdown” after the birth of her second child and that she had some counseling. When asked about the impact of their stress on their relationships with their children, they freely admitted that there was spillover. As one mother said about a time in her life when she was depressed about her daughters’ sexual abuse:

Back then I was always edgy, depressed. They always saw me crying. I couldn’t control it and at that time…I knew what they went through but it was basically what I was goin’ through. I didn’t want to face that part of what they’d been through, because if I had to face that, I had to face the [fact that] my husband…sexually abused them (M17).

The day-care mothers were also more open about their children’s emotional, behavioral, and learning problems.

Program Demands

Rules. In order to participate in the CRR, the mothers with severe mental illness were expected to conform to a set of rules. They were required to take care of their children; maintain reasonable housekeeping standards; abstain from using substances; and either participate in a mental health program (such as partial hospitalization) or attend a vocational training program, school, or work. Those who used the social rehabilitation program were expected to drop their children off and pick them up at the designated times and to devote one day a week as an assistant, at which time they could observe the teachers model parenting skills. Although medication compliance was not a condition for remaining in the residence, mothers were strongly encouraged to take their medication. Participants were also expected to keep individual appointments with physicians, psychiatrists, counselors, welfare workers, and others. Although male friends could visit and the women could go out with them, overnight male visitors were prohibited. Residents were expected to maintain contact with program staff, including the counselor who was assigned to them, and to attend group meetings that were convened every month.

When asked what the rules were, the mothers accurately recited them. Interestingly, however, each emphasized and often added a personal issue. Thus, M1, who came from a home in which violence occurred, said, “You’re not allowed to hit other people.” Clients who had histories of substance abuse mentioned that drugs and alcohol were not allowed. One woman complained about the prohibition of overnight visitors.

Participation in mental health programs. Most of the women with mental disorders participated in a partial hospitalization program at a nearby community mental health center, about which almost all of them expressed negative feelings. Their chief complaint was that the program was boring. One high-functioning mother said that she did not feel that she fit in The mothers also complained about the social rehabilitation program, which was 45 minutes away by bus. The mothers felt that they spent too much time traveling, a situation that was remedied the following year when the child-care center was moved to the apartment complex where they lived. Although the mothers expressed dissatisfaction with this program, their behavior indicated otherwise. They were observed remaining at the program beyond the drop-off time, apparently socializing (or avoiding leaving for the partial hospitalization program). One mother came early. Attendance, however, was not regular. Mothers did not show up to assist on their assigned days or fell asleep after they arrived. Even though the program worked on goals for parents as well as children, the mothers did not perceive the program helpful with their parenting skills. Several of the mothers said that they already knew how to parent, that they had learned these skills from members of their own family.

The nonverbal behavior of the mothers with mental illness suggested that these mothers wanted to elude the mental health system. As indicated, they conformed minimally to expectations, complained about the system, and frequently missed social rehabilitation and partial hospitalization. Two mothers who completed the program left no forwarding addresses. One of the staff members remarked that it was not unusual for those who terminate to drop out of the system afterward.

In contrast, the day-care mothers were appreciative of the services provided by the daycare center and felt that the rules (e.g., drop-off and pick-up times) were reasonable. They said that they were expected to attend parent meetings, but many were not able to do so because of their busy schedules. Furthermore, the day-care mothers were more open about difficulties they had disciplining their children and juggling responsibilities.

Psychosocial Issues

Desire for normalcy. All of the mentally ill mothers expressed the desire to develop a normal life for themselves and their children. They wanted to obtain or maintain custody of their children, have their own apartment or home, own a car, and get married.

My hopes and dreams are for, first, my kids. I want them to grow up in a decent, pleasant, lovable environment that doesn’t have any fighting, arguments, you know, any kinda physical abuse. I want to have a nice home where I can own some day….I’d like to just live the rest of my life out with my kids in peace and, you know, have a nice home in a country setting (M1).

Another mother said, “I prefer to be married….Marriage would be more stable for me….Yeah, you know, if I can have my oldest daughter and can be a real family” (M5).

Almost all of these mothers said that they would like to work or go back to school, but several were concerned that working would compromise their entitlements. Two women said that they would like to have careers in music. As for their children, the mothers hoped that they would complete high school without getting thrown out or becoming pregnant. Some mentioned that they would like their children to go to private school and college. Several said that wanted their children to play an instrument or participate in sports. They also expressed fears that their children would be exposed to dangers in the neighborhood.

The aspirations and fears of the day-care mothers were similar to those of the mothers with mental illness. They wanted to lead secure, peaceful lives with their children. They stressed the importance of their children’s education and hoped that the children would avoid their mistakes.

The context of the aspirations of the daycare mothers, however, was different from that of the other group. As students and employees, they gave work a high priority and expressed mixed feelings about developing permanent relationships with men.

At one time, if you were to ask me that “[What would you like for yourself in the future?”], maybe about six months ago, I would have said, “Well, I want to meet me a good man.” But now that’s not even the case anymore. I want me a good job (M17).

You have to be strong. If you’re not strong, you won’t make it. And you can’t really depend on…You have to depend on yourself. You can’t depend on nobody else (M15).

This society is really hard on women. I mean they…give you programs that help some of them. They have these programs, you know, but it’s still not enough. We need the fathers (M14).

Need for help with parenting. The mentally ill mothers needed guidance as parents but did not acknowledge this need directly. The list of parent goals that were posted at the social rehabilitation program included limit setting and attendance. The children’s goals included compliance with verbal prompts, speaking, using a spoon, and refraining from clinging behavior and physical fighting. Observations revealed that many of the children were developmentally delayed and had behavior problems and that the parents had difficulty attending to or disciplining them. Nevertheless, most of the mothers acted as if they did not need help and had nothing to learn from the staff.

In contrast, the day-care mothers freely discussed their difficulties managing their children and their needs for support. Several alluded to the absence of a partner who could share the responsibility; some talked about having to learn through experience how to discipline the children.

Viewed selves as children. The interview and observational data also indicated that the mothers with mental illness viewed themselves as children rather than as parents. At the social rehabilitation program, the mothers would frequently participate in activities such as drawing similar to the way children might participate in such activities (e.g., the mothers would hang their pictures on the wall). Moreover, one of the themes that emerged from six of the interviews was “I’m a baby.” For example, “[When my children grow up] maybe they’ll take care of me” (M8). Another said, “In my family, I’m treated just like I’m 12 years old” (M9). Following an argument with a relative who became angry after she left her baby for three hours without calling and was asked, “Where were you?” one mother responded, “Don’t talk to me like I’m a baby anymore. I don’t have to answer to you” (M1).

Comparatively, only one of the eight day-care mothers made such a statement, and it was similar to that of M8.

Housing. A readily apparent need was for safe, affordable housing. Seven of the mothers with mental illness had a history of homelessness or unstable living situations. The community rehabilitation residence met this need, providing an environment in which the mothers could receive emotional support and parental guidance, It appeared that the mothers complied with the program’s expectations to the extent that they could remain in their apartments. Interestingly, those who complained the most remained in the CRR the longest.

Only one day-care mother mentioned a past problem with housing. Other needs mentioned by the day-care mothers included flexible, affordable day care, higher education, and help disciplining their children.

Several of the day-care mothers spoke about outlets that helped them relieve their stress. These included participating in the church choir, religion, spending time with friends, and going to clubs, school, and artistic activities. Some of the CRR mothers also expressed a love for music and religion.

Discussion

The mothers with severe mental illness perceived themselves as individuals who had experienced life difficulties. Their mental illness was continuous with other problems they had experienced–growing up in a dysfunctional home, being a foster child, death of a parent. Although they recognized that their problems were serious enough to result, in some cases, in hospitalization and the loss of custody, they tended to attribute their problems to factors other than their mental illness.

Parenthood was central to the lives of both groups of mothers. The children gave them focus and purpose, providing an anchor in their life. The mothers with mental illness lived in the CRR in order to stabilize their lives so that they could assume fuller responsibility for their children. Thus, the desire to assume the parental role seemed to motivate them to meet program demands.

Overwhelmingly, the mentally ill mothers wanted to live a normal life. Their aspirations (a stable home, marriage, a job) were similar to those of the day-care mothers and comparable to those of women in general. Their focus on their children was consistent with the findings of Schwab, Clark, and Drake (1991) and similar to that of the low-income single mother comparison group, although the CRR mothers were defensive about their parenting skills and less willing to acknowledge their difficulties.

It may be that the mentally ill mothers saw childbearing and parenthood as ways to affirm their normalcy. Parenthood is a pervasive human activity that connects one with the community. Although the sample was small, in all three cases in which the mother was pregnant during the interview, the mother had other children in foster care. The new pregnancies may have been a means to replace the children lost to foster care (Apfel & Handel, 1993). Replacement of a “lost” child with a “new” one may help restore continuity in the women’s lives and temporarily raise their self-esteem, but it does not help them resolve the loss (Simos, 1979).

However normal their aspirations, the mothers with chronic mental illness had divergent wants and needs. They wanted to live autonomously and reside with their children in the community, but they did not want mental health supervision. Nevertheless, they were dependent on others for guidance and support, which they simultaneously accepted and rejected. They complied with program demands in order to maintain their residential status but did not fully identify with the program. goals. They claimed they were adults but identified with and described themselves as children.

Apparently, a gap existed between clients’ overt and covert needs. The CRR addressed the women’s overt needs for housing, emotional support, linkage with mental health resources, and child care. With the exception of the social rehabilitation program, most of the services were either on site or nearby. The mentally ill mothers also had covert needs for both autonomy and dependence, which helped create their ambivalent responses to the program.

The mothers’ partial rejection of the CRR’s rich offerings raises questions about the strategies used to engage them as clients. This research found that the women were motivated by two needs to participate in the program–to obtain a stable living situation and to secure and maintain custody of their children. Regardless of their attitudes toward other aspects of the program, these are the ties that bind. Social workers who work in this program or similar programs should engage clients around these sources of motivation and collaborate with them to develop goals that help them realize their desires. When resistance is identified, workers should explore the source of the resistance and work with the client to resolve conflicts.

Because of the women’s past experiences with loss and the fear that they will lose their other children, these mothers were reluctant to discuss their need for help with parenting skills. This research suggests that staff should use indirect methods to teach parenting skills, such as covert modeling and demonstrating rather than telling them what to do. When parents perform skillfully, they should be complimented.

Nevertheless, women need “time to grieve” over past losses (Simos, 1979). Replacing a child lost to foster care or adoption with another pregnancy creates new problems for women who are already experiencing difficulties and places demands on a child, who may be meeting the mother’s need to demonstrate that she is normal. The women interviewed were sensitive about their losses but needed to resolve them. It would be helpful to engage them in grief counseling.

Another strategy is to refer the women to naturalistic rather than programmatic resources. Most of the women interviewed felt that the partial hospitalization program run by the community mental health center was inappropriate. Although this program provided structure and continuity, it was artificial and stigmatizing. Program staff should explore alternative activities and elicit the women’s suggestions about how to organize their time. Partial hospitalization programs should be encouraged to provide more stimulating activities.

A larger question has to do with intervention in light of the competing needs of the mothers and children. Although the mothers want custody of the children and affirm that the children are central to them, many of these mothers are more than ordinarily limited in what they can give to their children. Schizophrenia and other serious mental disorders are chronic conditions subject to exacerbation. The mothers are at risk of decompensating and multiple hospitalizations, thus threatening their children’s stability. Regardless of how strong the mother-child bond may be, children suffer the consequences of a disrupted relationship. Child welfare workers, mental health social workers, and others who work with this population must take into account the rights and needs of both mothers and children as well as the costs and benefits of maintaining these high-risk relationships.

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Roberta G. Sands is Associate Professor, School of Social Work, University of Pennsylvania, Philadelphia, Pennsylvania. This article is based on work funded by the University of Pennsylvania Research Foundation.

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