International Journal of Mental Health Nursing (2003) 12, 153–157

INTRODUCTION

Parenting is one of the most important but challengingtasks that most of us encounter. In some families it is madeeven more difficult by the presence of parental mentalillness which can sometimes result in psychological, emo-tional and behavioural problems in the children (Beardsleeet al. 1983; Rutter & Quinton 1984; Rutter 1966). Researchhas shown, however, that it is not the mental illness itselfas much as its chronic nature and associated psychosocialproblems that contribute to the impact on children ofparental mental illness (Beardslee et al. 1983; Rutter &Quinton 1984; Silverman 1989). The negative impact onchildren stems largely from difficulties with parenting andlack of emotional involvement (Cooper & Elliott 1997;Rutter & Quinton 1984; Silverman 1989). Disruption anddisorganization in the family due to ongoing illness andrepeated hospital admissions also impact on the children(Cooper & Elliott 1997; Cowling et al. 1995; Cowling1996).

MOTIVATION AND MENTAL ILLNESS

Lack of motivation is another difficulty facing some parentswho experience mental illness and has been reported asleading to poor parenting (Buist 1998), neglect of children(Appleby & Dickens 1993) and limiting the use of avail-able services (Luntz 1995).

Lack of motivation or apathy may be either a directsymptom of mental illness, as in severe depression(Appleby & Dickens 1993) or caused by the use of certainantidepressant medication (Buist 1998; Krupp & Fogel1997). Lack of motivation and initiation can also be symp-tomatic of frontal lobe dysfunction, or ‘executive dysfunc-tion’ which is seen not only in cases of frontal lobe damage,but also in psychiatric illnesses, especially schizophreniaand affective disorders (Austin et al. 1999; Mahurin 1999).Research has shown a wide range of symptoms associatedwith frontal lobe damage, or dysfunction, which includelack of motivation, apathy, disturbances of affect and mood,and lack of initiation (Al-Adawi et al. 1998; Stuss et al.1992). The concept of ‘executive dysfunction’ similarlysuggests problems with planning, initiating and maintain-ing goal-directed behaviour, which impacts on everydayfunctioning by reducing the individual’s ability to organizeand perform everyday tasks. The impact of this can be con-siderable in terms of personal safety, independence andstandards of personal care (Mahurin 1999), which of courseare also felt by any children who are dependent on thatadult.

RESEARCH NOTE

Parents with mental illness: Lacking motivation toparent

Correspondence: Ross Kalucy, Department of Psychiatry, FlindersMedical Centre, Bedford Park, SA 5042, AustraliaEmail: ross.kalucy@fmc.sa.gov.au

Lyndall Thomas, BA (Hons).Ross Kalucy, MBBS, FRANZCP.Accepted March 2003.

Lyndall Thomas and Ross KalucyDepartment of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia, Australia

ABSTRACT: Parents with mental illness sometimes struggle to manage the demands of a family andthe disabling symptoms of their illness. Limited interaction and poor relationships can negatively impacton children. Lack of motivation may inhibit these parents’ ability to interact with, and provide adequatecare for their children. This is especially problematic following a hospital admission. Lack of moti-vation, in psychiatric illnesses, can be a symptom, due to medication, or perhaps associated with frontallobe disorder. Assessment, rehabilitation and support that focuses on parents’ problems with motivationand planning and enhances their parenting would be beneficial in helping parents with mental illnessprovide the best possible care for their children.

KEY WORDS: frontal lobe disorder, motivation, parents with mental illness.

Lack of motivation and initiation tends to reduce thelevel of involvement and interaction with children, some-times to the point of neglect. Especially when coupled witha sense of disorganization, some parents with mental illnessare neither interacting with their children nor performingbasic parenting or household functions for their children.For some parents with mental illness the effects of theirsymptoms, medication or perhaps frontal lobe dysfunctionmay make the organization and effort required for par-enting almost impossible unless appropriate assessment,rehabilitation and support is provided.

We interviewed parents with mental illness regardingthe impact of their illness on their children and familiesand found that lack of motivation was a problem that ledto long periods of relative inactivity. This lack of motivationwas described as both ‘not feeling like doing anything’ and‘being disorganized, not knowing what to do or being ableto get started’. This paper will discuss some of the findingsof this qualitative research that relate to the difficulties thatparents described about lack of motivation and inability toplan and initiate activities and how this affects theirfamilies, especially children, and impacts on their dailylives.

THE PARENTS WITH MENTAL ILLNESSSTUDY

This study was initiated by a group of mental health con-sumers who wanted parents to have an opportunity to talkabout their experiences of parenting and how having aserious chronic mental illness affected their children andfamilies. Ethics approval for the study was received fromthe Research Ethics Committee of the Flinders MedicalCentre, Adelaide, South Australia, Australia. Participantswere recruited through inpatient and community mentalhealth services from the southern suburban areas ofAdelaide.

All participants were parents who had been responsiblefor the care of their children at some time while sufferingfrom a serious long-term mental illness. The 35 partici-pants, 28 mothers and seven fathers, reported diagnosesof schizophrenia, schizo-affective disorder, bipolardisorder and major depression and had been hospitalizedan average of eight times. The parents had an average of2.5 children whose ages ranged from 2 years to 36 years.Six of the fathers lived with spouses, but only nine of themothers did. Six participants’ young children were notliving with them at the time of the interviews. Three partici-pants had children living with another parent, one mother’schildren were in foster care and two parents had childrenliving with grandparents.

The consumers involved in the development of thestudy contributed ideas for the framework of the questions

for the interviews. A semistructured format covered fourmain themes: (i) impact on daily life; (ii) problems associ-ated with hospital admissions; (iii) ongoing managementof the illness, and (iv) recommendations for changes to services that would assist them as parents. Interviewswere taped and transcripts analysed with the aid of theNUD*IST program (Qualitative Solutions and ResearchPty Ltd., Melbourne, Vic, Australia). The consumer rep-resentatives reviewed the findings prior to publication ofthe final report.

The main findings from this study revealed that:(i) parents had little interaction with their children andpoor insight into how their illness might effect theirchildren; (ii) children were sometimes isolated whenparents were unable to assist them to socialize; (iii) childrenhad little understanding of the parent’s illness and it wasoften not discussed; (iv) where good support was available(spouse or grandparents) it was heavily relied upon; and(v) when good support was not available care of childrenand general household tasks were often neglected.

These responses reflect similar issues as identified inother literature (e.g. Bassett et al. 1999; Cowling 1996;Devlin & O’Brien 1999; Fox 1997; Handley et al. 2001;Mannion et al. 1994; Rimington 1998). For a full descrip-tion of the present study see Thomas and Kalucy (2002).

PROBLEMS WITH MOTIVATION ANDINITIATION

The other main finding from the study was that more thanhalf of the participants reported that they had little inter-action with their children and often did not feel like doingthings with or for them. Other comments indicated thatparents undertook minimal responsibility for the care oftheir children, sometimes to the point of neglect, and reliedheavily on others for help. Lack of motivation may beresponsible for this inability to initiate activities and planor organize child care and household tasks.

Nature of the difficultiesOne mother [S1] told how her bipolar disorder impactedon her two young daughters.

I never had enough time for them, I always wanted to liedown and rest … I used to ignore them all the time, justleave them on their own when they were too young to beleft alone.

Some parents reported that their children weresomewhat isolated, having little contact with friends awayfrom the school environment, as they did not feel like beinginvolved in activities and socializing with their children.One single mother [S2] reported:

Yes, he has lots of friends, but we have become isolatedlately because I don’t always feel like doing things.

154 L. THOMAS AND R. KALUCY

Responses to questions about the impact on everydaylife and difficulties returning home from hospital admis-sions often revealed problems with motivation, apathy and suggestions of difficulties with planning and initiatingtasks that need to be performed as part of the daily home-keeping and parenting role. A single-mother of youngchildren [S3] recalled:

… I neglected them a bit … sometimes I would forget tobath them for 4 or 5 days and things like that.

Another mother with schizo-affective disorder [S4] told of difficulties on return from an extended hospitaladmission:

I was disorganized, didn’t know what to do and didn’t feellike doing it.

For some, basic household chores and routines areforgotten during acute episodes and in the early weeksfollowing hospitalization. One mother [S5] used notes toremind her of the things that needed to be done each dayand the order in which they should be carried out, other-wise she did not know how to begin. For others, this lackof motivation or inability to initiate tasks is coupled withthe loss of ability to perform simple automatic tasks suchas tying shoelaces, counting money or preparing simplefoods. Thus for some, the return from hospital does notalways mean that life returns to normal, as the parent mayfor some days, or even weeks, still spend much time doingvery little and contributing little to the parenting andhousehold responsibilities.

Extent of the problemWhile the cause of parents’ limited interaction is notcertain, it was clear that the low level of activity often con-tinued for long periods after hospital admissions, and forsome parents was an ongoing difficulty. Many parentsreported that they felt far from well when discharged andit may be 3 or 4 weeks before they felt completely well andfunctioning as usual. During this time parents were some-times very inactive. A mother [S6] whose children are nowadult recalled:

… often there is no-one else around to make you realizethat things must be done, some people will sit around allday because they can’t think what to do and are not moti-vated to do anything … I have had days shortly afterhospital stays where I have spent the whole day in bed …

This lack of interaction and activity is likely to impactnegatively on the children who were sometimes isolated,left alone for long periods and perhaps receiving inade-quate physical and emotional care.

Possible contributing factorsSome of the questions asked the consumers’ for their viewson being in hospital. Twenty per cent (n = 7) complained

that there was not enough to do while in hospital, while a further 14% (n = 5) said that being in hospital ‘doesn’tprepare you for going home’. Some of the parents felt thatthe lack of activities in the hospital and the rigid routinesare incompatible with home life and parenting in partic-ular. One woman [S1] said:

It’s not like home, I think they should let us use the vacuumcleaner and clean our own rooms, that is practical stuff likeyou have to do at home.

Others felt that too much time spent lying around mayalso contribute to motivational and organizationalproblems, as with no need or incentive to do anything, itcan become a habit. A mother of two young children [S2]talked about establishing routines after returning home.

After six weeks in hospital where you don’t have to do athing … no responsibility for the children … I was disor-ganized and found it hard to concentrate and get a routinegoing again.

Lack of motivation and inability to plan and organizedaily activities may also contribute to the tendency forthose parents in the present study who had a supportivepartner to be very reliant on them, and not make any effortto contribute or do things for themselves or their children.In some families this is a permanent state, as it was apparentthat the parent often did very little at all. A father of threeyoung girls [S7] said:

My wife pretty well does most things all the time … I don’tlike money, … I can’t pay bills and stuff like that, … I can’tdrive the car any more.

A mother with teenage sons [S8] commented that she‘couldn’t cope without the regular support of my mother’.

What might help?The idea of rehabilitation or training in parenting andhousekeeping skills seemed to be important as 80%(n = 28) of the participants in this study reported that theyfelt far from well on their return home from hospital, andmany reported difficulties in resuming their parentingroles. Specific difficulties included cooking, washing andgoing to the supermarket, while more generally the parentstalked of problems being organized, and knowing what wasneeded to be done. While some parents attributed this dif-ficulty to developing bad habits and getting out of practicewhile being in hospital it is also likely that the difficultiesare directly related to symptoms, medication or perhapssome level of frontal lobe, or executive dysfunction. Thecause is usually unknown, but most parents reported thatthey returned to their usual level of functioning within afew weeks without the need for altering medication. Othersseemed to be troubled by poor motivation, problems ini-tiating activity and some loss of cognitive functioning forlonger periods.

MOTIVATION IN PARENTS WITH MENTAL ILLNESS 155

Parents’ inability to remember how to do simple,routine or automatic tasks suggests that during and fol-lowing a serious episode of illness that requires a hospitaladmission some cognitive deficits result. While generallytemporary in nature, it is likely that some parents withmental illness need additional support over a period of timeuntil they are functioning at their usual level. When askedabout the types of assistance that would be useful follow-ing an admission, 25% (n = 8) said that practical assistancearound the home would be the most important, to helpreduce the burden on carers and minimize disruption tothe family. One mother of adult children [S9] suggested:

… someone to assist me with tasks … guide me until I havemy confidence to do things on my own again.

Another who had experienced postnatal depression[S10] said that more follow-up from her mental healthworker ‘who could be directive and helpful at a time whenI was not able to think and function clearly’.

DISCUSSION

Currently in South Australia little is offered to psychiatricpatients by way of rehabilitation to help them resume theirparenting roles again. Similarly, consumers are not rou-tinely assessed for cognitive deficits that may be directlyattributed to their mental illness, such as ‘executive dys-function’ or evaluated on their ability to take care of them-selves or others in the home environment. Nicholson andBlanch (1994) have reported that in the USA there waslittle assessment or rehabilitation aimed at helping parentswith mental illness cope with their family responsibilities,placing children at unnecessary risk of developmental orpsychiatric problems.

Assessment and rehabilitationAppropriate assessment that identifies specific cognitivedifficulties and rehabilitation which focuses on re-establishing domestic and parenting roles could helpovercome problems of lack of motivation and initiation andreduce the risk of neglect for children (Nicholson & Blanch1994; Silverman 1989). Nicholson and Blanch (1994) havesuggested that assessments of basic living skills, which alsoevaluate the parenting role and child-care ability, shouldbe used to guide rehabilitation programs for parents with mental illness. This needs to include qualitativeassessments of parent–child relationships, interaction andattachment, as these are important in providing the emo-tional and psychological needs of the children necessary toprevent the emotional and developmental problems thatchildren exposed to parental mental illness are at increasedrisk of. Special attention may be needed to train parentswith mental illness in how to maintain good relationshipsand continue social functioning in the face of ongoing

psychiatric symptoms. Unfortunately, this type of assess-ment and assistance is often only provided to parents withmental illness after welfare agencies have been notifiedabout neglect or abuse of children resulting from inade-quate parenting.

Practical supportThe idea of providing practical assistance to people withmental illness is counter to current views that see thisapproach as encouraging dependence on that support.Indeed in this study, those parents with good personalsupport were highly dependent on it. However, practicaladvice and more structured help may be needed to guideand instruct, to encourage action when self-motivation islacking or a sense of not knowing what to do prevents anyactivity being initiated. This type of support may be assimple as a phone call each day to discuss with the parentwhat he/she needs to do and to provide tips to encouragethe re-establishment of routines and organization that canhelp overcome the problems of poor motivation and lackof ability to get started. For example, the idea of using notesto remind of tasks to do each day, as reported by onemother, is a simple strategy that could easily be conveyedto struggling parents during rehabilitation sessions or infollow-up contact. Such support may only be needed overa limited time and should not lead to dependence as theparent gradually returns to their usual level of functioning.

CONCLUSION

Given that more than half of the parents in the presentstudy reported that they had little interaction with theirchildren, and a similar number complained about thedifficulty in completing the normal household and child-care tasks required of parents, it seems that many of theirchildren are at risk of developing emotional or behaviouralproblems, if not neglected. As some of the most frequentsuggestions from parents in this study were for additionalservices related to practical assistance with householdresponsibilities, it seems that good assessment and specificshort-term support and advice with both practical childcare and domestic tasks, and in maintaining good rela-tionships with their children may be the most effectiveoption.

Neurological testing and assessment that identifiedspecific difficulties coupled with rehabilitation, training or support that provided strategies to help overcomeproblems could assist parents with mental illness to resumetheir parenting responsibilities and foster self-reliance.Appropriate cognitive and social skills assessment thatidentifies strengths and deficits could guide rehabilitationand support services so that they are specific for individ-ual’s needs and less likely to become relied upon.

156 L. THOMAS AND R. KALUCY

The group of parents interviewed in this study were allsuffering from serious chronic mental illness and theirneeds for ongoing support following hospitalization maybe greater than for other parents with less severe mentalhealth problems. Thus, the findings from this study maynot be generalized to all parents with mental illness andfurther investigation and trials of different rehabilitationand support programs is warranted.

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