When Laura Metcalfe was stressed over a significant health problem that required surgery, she tried to hide her anxiety from her two young children. “I was going for a lot of treatment and at the time I didn’t have a partner. I was stressed over childcare; I was stressed about money.”
She soon realised these challenges to her mental health were having a “trickle-down effect” on her young daughter Emily and her little brother. “The children were becoming more and more withdrawn,” says Laura, who has autism and was attending a psychologist for her anxiety but didn’t know where to go for help with the children. Contact with the Child and Adolescent Mental Health Services (Camhs) had been a dead-end. “They spoke to Emily, but they didn’t want to take her on. Unfortunately, we just didn’t fit between their parameters.”
An estimated 23% of all families have at least one parent who has, or had, a mental health disorder
She expressed her frustration to her psychologist who offered to refer them to a research project that was piloting a family-focused programme called Family Talk. Developed in the US and adapted by the researchers for use in Ireland, Family Talk is a six- to eight-week course aimed at supporting families where a parent has a mental illness. It includes sessions for the parents, the children and the whole family together. An estimated 23 per cent of all families have at least one parent who has, or had, a mental health disorder. Research shows the lifetime risk of mental illness for children in these families is increased by between 41 and 77 per cent.
The Health Service Executive (HSE) funded Maynooth University's Centre for Mental Health and Community Research (CMHCR) to evaluate the use of Family Talk in helping to break the intergenerational cycle of mental illness. The main aim is to improve communication between family members, thereby strengthening relationships and resilience within the family.
Before doing Family Talk, Laura and Emily both thought they were helping the other by not sharing what was on their minds. Laura didn’t know how to tell her daughter that she was sick. “If she caught me in a stressed moment, I would always say ‘It’s okay, it’s nothing’ and she would think it was something to do with her.”
‘Both scared’
Emily didn’t understand what was going on, but didn’t want to burden her stressed mother with her own worries. “I bottled things up by not talking,” Emily, now aged 12, tells The Irish Times. “Not talking to each other made things worse. We were both scared.”
“We both felt there was strength in silence,” says Laura. “When, in fact, talking about our emotions was the bravest thing we could do.”
When the two of them sat down to do Family Talk sessions with a facilitator in their own home more than three years ago, it broke down the communication barriers between them. While some of what Emily said was difficult for Laura to hear, it was “at the same time freeing”, she says. “I realised that by shielding her, I was blinding her. You can’t grow a flower without any sunlight. When she opened up to me it was huge because I realised then I was doing more damage by not talking to her.”
“It got much better for us almost immediately,” agrees Emily, who has recently been diagnosed as being on the autism spectrum. “I now understand that every person gets stressed and scared sometimes.”
Two-thirds of families found participating in Family Talk “significantly beneficial”, according to the results of the five-year Primera study, which were released earlier this month (May). Researchers found fewer child behavioural and emotional problems at a six-month follow-up. Family relationships had improved; parents had more understanding of the impact of mental illness on their children, while children understood their parents’ symptoms better, and affected parents felt more able to cope.
The director of the CMHCR and principal investigator for this research, Prof Sinéad McGilloway, is calling for “think family” policy and practice to be incorporated as a routine part of both adult and child and adolescent mental health services.
Next generation
“When child welfare is not considered in the treatment of parents with illness, our services are failing to identify a portion of children and adolescents who are at significant risk of becoming the next generation of mental health service users,” she says.
Ireland is rated to have the third-highest incidence of adult mental illness across 36 countries in Europe – costing the State €11 billion per year. It is estimated that 280,000 children are dependent on parents who have a mental health illness.
We have evidence that Family Talk works and it represents really good value for money, says McGilloway. The research has estimated it costs €683 per family to deliver but only €307 per family when non-recurring costs, such as clinician training, are not included. “These are tiny figures in relation to the potential impact,” she argues. Mental illness casts a very long shadow and while this programme is not a “magic pill”, there is evidence that it is really helpful.
School teacher Declan Murphy, who is trained in a trauma-informed approach, sees Family Talk as an opportunity to change a generation. He knows all about the vulnerability of children who have a parent with a mental illness, both from research and first-hand experience.
His mother was diagnosed with bipolar disorder in the 1980s when he and his three siblings were in their formative years, all under eight. “The impact was enormous because she was regularly suicidal and we would have witnessed suicidal attempts,” he says. She was in a psychiatric hospital for long periods, “so there was a lot of separation, which obviously impacted on our attachment and development”.
He recalls mixed emotions about visiting her in such a setting. “On the one hand, you really wanted to see your mam, but then you went in there and it was really scary.”
During the years of her illness, there were no services to support their father, who was trying to manage their farm, his children and his wife, or to help them as youngsters to understand what was going on. “In the absence of visibility, and the stigma of this illness, you were left further estranged and alone. I think even good-intentioned friends, neighbours and family didn’t know how to help.”
‘Fight-or-flight mode’
He and his siblings would get very little sleep when their mother was in a manic phase and they struggled to get up to go to school. “Sport and school were really big interventions for us; we would have all flourished in our sport,” he says. “But academically it was so difficult because when you are in the classroom listening to the teacher, you are not able to concentrate or focus because your mind is wondering ‘Is Mam going to be there when you get home?’
“You are not in a learning zone when you’re traumatised; you’re in a survival zone where you’re hypervigilant all the time, scared, nervous.” Knowing well this effect of being constantly in fight-or-flight mode, it is easy for him as a teacher to identify children who are vulnerable and he is set to do a PhD on trauma-informed approaches in education and healthcare.
The emergency was gone but my body was still on fight or flight
By the time he was in his teens, his mother’s illness had settled after medication that worked for her was found. But the trauma didn’t end for him. “When the emergency of living with a parent with mental illness calmed, my body and mind then started to have a lot of anxiety and panic attacks. It was almost like the energy was still in my body; the emergency was gone but my body was still on fight or flight.”
Having talked to his siblings and mother the night before this interview, he reports that they all agreed a support programme such as Family Talk “would have been massive” for them. “It would have given us the recognition that ‘my mam has an illness and it’s okay’. We didn’t have a clue; we just knew the environment was terrifying.
“What was most shocking to my mother last night, and to my siblings, is that what we experienced in the 1980s, children today in 2022 are still experiencing. There is no identification of these children, so they are not being supported by Camhs or Tusla, and to me that is tragic.”
The Primera report calls for auditing of the parenting status of all users of the adult mental health services. “Where a parent has a known mental health disorder, the needs of their children or partners should automatically be considered and provided for, if so required,” says McGilloway.
Becoming a father himself in the last three years has heightened Declan’s passion for helping families affected by mental illness, as he reflects how, at his daughter’s age, he was already traumatised.
The “huge difference” Family Talk made to Laura and Emily is why they are both prepared to talk about it publicly. With waiting lists so long for services, “sometimes issues can spiral out of a person’s control”, says Laura. “If the funding was there for quicker interventions, it would give the individuals more resilience and confidence.
“We need to fix it at the child level,” she adds. “Otherwise they grow up as broken adults who are then raising broken children.”
Case study: ‘I was trying to tape everything together’
For a large part of Zoe Visser’s childhood, her mother was either in hospital or in bed most of the time at home as she struggled with her mental health.
“I kind of felt like she was a ghost,” says Zoe (17), but only after asking her mother to leave the room for this part of the interview. Although they are both totally committed to Zoe giving this honest, public account of the effects of having a parent with mental illness, there are still things she finds hard to say directly in front of her mother.
“She was there, but she wasn’t there. I felt like I was in charge of her because I used to feed her and give her her meds at certain times; I would be doing all that for her. I loved her but I wished I had a Mum that was there.”
I was trying to tape everything together when I didn't have much left in me to give
Zoe, who is second-youngest of her mother’s three children, took over the role of carer, scrubbing the house and teaching herself to cook so her father didn’t have to do it when he came home from work. She saw how that when she did that, he was able to sit down and spend time with them. “I was like ‘that’s how I get attention’. And I made him happy out.”
A good pupil at primary school, she used to talk to the principal but held back things she thought were “a bit much” as she didn’t want to get anyone else involved in their family. “I was trying to tape everything together when I didn’t have much left in me to give. My dad had always said I could come to him and I could talk to him but I just felt he had so much on his plate, which is weird looking back.
“I was far too young to be thinking that. But I wanted him to be able to enjoy himself and if that meant putting on a smile when he was home, that’s what I did.”
‘Severely suicidal’
In the last few months of sixth class, the impact of it all hit her: “The first person to find out was my principal and it took off from there.”
The school tried to get help for the family. “I was in Camhs because I became severely suicidal.”
She could see what her mother was going through and how it was affecting everyone. “I felt I needed to hide it away; that I needed to be strong as a child to pick up the pieces for my dad and for my mam and just be there.”
One particular night, when her mother had to be taken to hospital after a suicide attempt, is seared into her memory. She woke up with an ambulance outside the house, saw her normally bed-bound mother pass the bedroom door and her first thought was “you can walk?”.
“I said to her ‘where are you going?’ She just looked at me and her whole face was dropped and pale and there was black all under her eyes; I freaked out.”
After going to an upstairs window to watch her mother go off in the ambulance, she went downstairs to find her father with his head in his hands. He explained her mother wasn’t well and, as they had school in the morning, he couldn’t bring her to the hospital himself. But the next morning, he told Zoe her mother “had tried to do it”, to end her life.
“That kind of killed me,” she says. “It just felt like she was trying to put my hard work and all my dad’s hard work down the drain. That she didn’t care and we were after trying so hard for her.
“I didn’t understand because I hadn’t been through what she had been through. That turned into a lot of anger and people didn’t understand.
‘A lot worse’
“I felt I couldn’t tell anyone because I didn’t want to go to counselling because we didn’t have the money and we didn’t have the time because, if my dad didn’t work, we wouldn’t have food. I tried to keep it to myself and that ended up being a lot worse.”
Her first reaction to the idea of doing Family Talk was “this is another thing that isn’t going to work”. She was 14 by then and went along with it to help her mother. “I didn’t enjoy it. Now that I am older, I do actually see the benefits. But at the time I was not happy about doing it at all.”
Neither she nor her siblings gelled with the facilitator, and felt very uncomfortable talking about their trauma. It seemed to become stuck in their heads, she says, instead of something they thought they could cope with day to day. “It felt like it made things worse until the emotions settled down after a while. I think if my mental health hadn’t gone so far, it would have been better. But nobody knew, until a few months later, how bad I really was.” She has had psychiatric treatment for mental health issues and years of counselling since.
However, Family Talk “taught my parents a lot of skills that I can see now”, she acknowledges, and these are still benefiting the whole family as they take time to talk things through. Her mother has since been able to come off most of her medications, which has made a huge difference.
We have our ups and downs like any mother and daughter
Ironically, but understandably, Zoe found some aspects of her mother’s improving health difficult. While “having her around helps”, Zoe also at times resented finding her cooking food when she was going to do it, or her mother offering to help with homework. “I felt like my responsibility had been taken away from me. My brain had already matured to the point, ‘I have been doing this since I was a child, I don’t need you, in the nicest way possible.’ It was really hard to adjust.” But their relationship is good now.
“We have our ups and downs like any mother and daughter. We did lose our relationship a few years ago. I stopped talking to her for a year. I didn’t want to show her I was angry.” However, she acknowledges that this teen tactic just caused more problems for her mother.
What about Zoe’s own mental health now as she prepares to sit the Leaving Cert on June 8th, with the ambition to become a chef?
“I really never thought I was going to make it to my Leaving Cert and do things with my life,” she admits. “But I’m good; I’ve got plans for my future and going to hopefully start college. I’m happy out.”
