Abstract
When you have been through that… you can never be happy, you can never laugh as others do, you always have to be ashamed of yourself and take care not to break down yourself.
[Quote from the offspring of a person with schizophrenia in Manfred Bleuler's study, The Offspring of Schizophrenics]
Many of us will face mental illness at home as well as at work. Despite high prevalence and the advances of psychotropics and DSM, the guilt and shame of having a family member with a mental illness is usually immense, especially for children. On the evidence provided by this book, how we understand and treat those closest to our patients has advanced little since Bleuler's time. With luck, a patient's family might be consulted – with the expectation that they will continue to provide extraordinary support – and be psychoeducated. Unfortunately, we are all familiar with family members' accounts of having been excluded or brutalized by the caring system.
So, if there is a stark need for assistance in improving professional theory and practice, how helpful is this book? How does it differ from Vicki Cowling's earlier book, Children of parents with mental illness?
Like the earlier book, some of the strongest sections are like round-table discussions with consumers: stories of passion and a welter of ideas. In the middle of this book, three daughters describe how they have lived with mothers suffering bipolar disorder, Huntington's disease and schizophrenia. These accounts of beauty, degeneration and struggle justify the cost of the book. They illustrate the complexity of adversity and resilience in contrast with the reductionism required by categories of expressed emotion. One of the conclusions drawn by Kim Blair, who later trained as a mental health nurse, is that ‘psychoeducation isn't everything… it doesn't take into account the child's need to first express any anger, pain and unmet needs they may have’.
Some of the chapters written for professionals are excellent. David Hay makes the genetics of mental disorder disarmingly simple and emphasizes how, when applied to genetic counselling, the ethical, emotional and practical consequences are often troublingly complex. Whereas the first book expounded the importance of talking with children, here Adrian Falkov offers practical advice about how to talk and listen to children whose parents experience mental illness. Graham Martin and Tracey Kay trace the life of a parentified 12-year-old boy for whom family expectations sowed seeds of loyalty and dependability but limited his opportunity to develop the capacity for intimacy. Hypothetically they consider how this boy's life may have benefited from the protective interventions of: reducing personal impact and negative reactions; promoting esteem and opportunities and positive cognitive processing of negative experiences. The importance of peer relations, particularly in adolescence, is given its due and there is an excellent chapter on working with families from a different culture.
The editor made some mistakes. One account of 2 years of individual therapy is more concerned with the experiences of adoption in another time and place than of familial mental illness. George Halasz argues that children of mentally ill parents pass unnoticed because of ‘the current crisis… arising from both struggle at the heart of psychiatry and the reflection of a wider social and cultural upheaval.’ This analysis is provocative but misplaced: neither the polemic nor the account of a composite case with chronic headaches focuses upon the book's topic.
The uncertainty about what this book should cover reflects the immaturity of social psychiatry. The families of our patients offer some of the best opportunities for preventative and early interventions. Yet mainstream understandings have scarcely advanced beyond the case examples of Bleuler. Several decades of theorizing about the family have not been integrated into our eclectic adaptation of Engel's bio-psycho-social model in which the individual and biology are ascendant. While cultural movements like the mainstreaming of nineteenth century institutions and destigmatization point the way, is contemporary psychiatry ready for family-based practice?