Risk and resilience in the narratives of adult children of parents with psychosis

ABSTRACT

Objective

Children of parents with psychosis report feeling burdened and can experience poorer physical and mental health outcomes. Understanding the experience of adult children who were raised by a parent with psychosis in terms of risk of and resilience can inform how practitioners work holistically with the whole family.

Method

In-depth narrative interviews were conducted with adult children raised by a parent with psychosis. During the interview, participants were invited to tell their life story and how they felt their parent’s mental health had impacted them. Data were analysed using narrative methods. A core story was created for each participant and key themes were generated.

Results

Four female participants took part. Lucy described the resentment she held after seeing her mum change from a working mother to someone with mental health difficulties. Salma described how her father’s mental health was ‘normal’ for her and the stigma that affected her family. Hannah and Amelia described their own experiences of psychosis as adults and the interrelationship between a parent and child’s mental health.

Discussion

Multiple factors appear to influence the impact of a parent’s psychosis on children. These included the timing of the onset of psychosis, the extent of their exposure to the acute positive symptoms of psychosis, and the presence of a second parent who did not experience serious mental health difficulties. Healthcare professionals working with parents have a unique opportunity to work holistically with the family to modify the impact of parental psychosis on children.

KEYWORDS:

• Prevention
• Early intervention
• Psychosis
• Parenting
• Qualitative
• Narrative methods

Introduction

One quarter of children in the UK are affected by maternal mental health difficulties (Abel et al., 2019), the majority of which are common mental health problems such as depression and anxiety. Although fewer children are affected by parental psychosis (Abel et al., 2019), they are at a particularly high risk of poor physical and mental health outcomes (Pierce et al., 2020; Rasic et al., 2014). During infancy, children affected by parental psychosis are more likely to have poor attachment to their caregivers (Davidsen et al., 2015), and are more likely to experience childhood obesity and asthma (Pierce et al., 2020) than other children in the community. Children living with parental psychosis are also at a higher risk of experiencing childhood trauma (Brandt et al., 2022) compared with other children their age and are three to five times more likely to have received a psychiatric diagnosis by the age of seven (Ellersgaard et al., 2018).

There are multiple risk factors for children living with parental psychosis. First, genetics can play a role as psychosis has been found to be highly heritable (Bienvenu et al., 2011). Second, the symptoms of psychosis can adversely affect the parent–child interactions making it more difficult for a parent to provide responsive care (Radley et al., 2022). Finally, the environment can also pose a risk. Children may experience their parents being absent due to hospitalisation, and anyone affected by serious mental health difficulties, including parents, are more likely to experience poverty and have less social support (Luciano et al., 2014). Protective factors for children living with parental psychosis include having a dual-parent family, a positive home atmosphere, social support from peers, and the absence of poverty (Hosman et al., 2009; Riches et al., 2019).

Numerous factors will influence what kind of impact parental psychosis might have on children, including whether their parent is hospitalised, whether their parent experiences a first episode after their birth and how old they were when an episode occurred (Dam & Hall, 2016). Indeed, most parents with psychosis experience psychosis onset after becoming a parent rather than before (Mowbray et al., 2005). Living with, and being raised by, a parent with psychosis exposes children to more responsibilities and adult roles, compared to other children of the same age.

When children of parents with psychosis have described how they have been impacted by their parent’s psychosis, they have reported feeling burdened when their parent has been in hospital (Somers, 2007), embarrassed when seeing their parents cope with positive symptoms of psychosis (Valiakalayil et al., 2004), and feeling like they might be to blame for their parent’s distress (Östman, 2008). Later in life, adult children of parents with psychosis have described how knowing about the high risk of poor mental health made them hypervigilant for any symptom onset in themselves (Homberger, 2018). Previous research with adult children of parents with mental health difficulties has highlighted the responsibility they assumed during childhood (Foster, 2010) as well as the lasting impacts on their own interpersonal adult relationships (Patrick et al., 2019). Some adult children of parents with psychosis have noted that they found it difficult to form an attachment with others in adulthood (Källquist & Salzmann-Erikson, 2019). Some have described how their experiences gave them the necessary empathy and motivation to care for others (Blakeman et al., 2019).

Interviewing children of parents with psychosis when they are adults can help to understand how they perceived their parent’s mental health to have had an impact on them. This impact can be understood in terms of both risk and resilience with regard to their mental health and wellbeing. An understanding of these factors can be used to inform the development of preventative interventions. This study explored adult children’s perceptions of the impact of their parent’s mental health. This study used narrative methods to analyse the results in order to retain the richness of each story.

Research question

As adults, how do the children of parents with psychosis perceive their parent’s mental health has impacted them?

Methods

Design

The study was given ethical approval by South Central Oxford C Research Ethics Committee. In-depth narrative interviews were conducted with adults who had been raised by a parent with psychosis. This study was underpinned by the use of narrative methods (Smith, 2016), focusing on the content of participants’ stories of their parent’s psychosis, including their childhood memories, how reflecting back, they made sense of it, and how they feel it impacted them. Unlike in other qualitative methodologies, such as reflective thematic analysis (Braun & Clarke, 2006), the aim of narrative analysis is not to fragment the text into codes in order to identify common themes or patterns across participants; instead the aim is to analyse the key themes in each participant’s narrative story. The design meant that we planned for a small sample.

Participants

Participants were eligible if they were over the age of 18, and lived with a primary caregiver had who experienced psychosis during their childhood, for at least half of the time (4 years) between the ages of 3 and 11. This age range was chosen to ensure participants had lived with their parents pre-adolescence and were old enough to remember this period of their lives, and to ensure we were focusing on a sufficiently narrow age range so participants’ responses could be interpreted meaningfully. Participants were recruited in two ways; local GP surgeries were asked to display a poster with information about the study, and an advertisement was placed on a university recruitment opportunities webpage.

Procedure

Potential participants who contacted the primary researcher were sent an information sheet. Eligibility criteria were checked and the researcher answered any questions from potential participants. Participants were given at least 24 hours to decide whether they wanted to take part, after which those individuals who were willing to take part gave their informed consent.

Prior to the interview, participants completed a short demographic questionnaire regarding i) age, ii) gender, iii) parent’s gender, iv) parent’s psychiatric diagnosis (if known) and v) whether their parent was hospitalised during their childhood. The aim of the subsequent interview was to elicit a full narrative with as little interviewer interjection as possible. The first question posed in the interview was ‘Could you please tell me the story of your life paying particular attention to the role that your dad’s/mum’s psychosis played.’ It was intended that participants would speak for 15 to 30 minutes after which follow-up questions tailored for each participant were asked, to encourage them to elaborate on key aspects of their story, and to create long turns at talk during the interview (Riessman, 2008). Follow-up questions were unique to each participant depending on the content of their narrative. Interviews were audio-recorded and then transcribed by a transcription service.

Analysis

Narrative analysis is used to understand how individuals make sense of events and actions in their lives (Riessman, 2008). The aim of this approach is to keep stories intact; thus, the unit of analysis is the whole transcript. After familiarisation with the audio-files and transcripts, core story creation was undertaken to reduce each narrative to its core components, whereby all interviewer questions and all words which detract from the key ideas are deleted, and text is moved to create one coherent story or set of stories (Emden, 1998).

There is not one agreed procedure for narrative analysis (Smith, 2016). While some analytic methods are more concerned with the structure or purpose of stories, we were primarily concerned with the content and meaning of participants’ narratives as opposed to how the narratives were formed. Therefore, once a core story was created, thematic narrative analysis (Riessman, 2008) was used to answer the research question ‘As adults, how do the children of parents with psychosis perceive their parent’s mental health impacted them?’ When generating themes from the core story, particular attention was paid to participants’ life stages and the relationship between the story of their childhood and their reflections as an adult.

This thematic narrative analysis was reported individually rather than searching for patterns of meaning between participants to maintain the richness of each story. Some elements of participants’ stories were not referenced explicitly to preserve anonymity. Participants were sent copies of their core stories and the accompanying analysis. They were asked whether they felt it reflected their perspective, as well as what they would like their pseudonym to be. Three participants responded and said that they felt the analysis reflected their experience. Two out of the three participants who responded made small suggestions which were incorporated into the analysis. For example, one participant asked for the word ‘hope’ to be changed to ‘health.’

Results

Four participants enquired about the study and all four took part between December 2019 and January 2020. All participants were female. Two participants were in their twenties and two in their forties. Three participants had lived with a mother who had experienced psychosis, and one participant lived with her father. In the interest of maintaining anonymity no further demographic details are provided on participants.

Lucy’s story

Lucy is a 23-year-old woman whose mother developed psychosis when Lucy was a teenager. Lucy’s story about her mother’s psychosis fell into two distinct phases of ‘before’ and ‘after’ her mother’s first psychotic episode. Lucy continued to feel resentment towards her mother and she was still actively trying to make sense of her mother’s psychosis and its impact on her childhood.

Two periods of life: before and after psychosis

Lucy described how when she was a teenager, her mum changed from being a ‘working mum’ in a high-stress job to becoming addicted to internet gaming, which was seemingly a trigger for her mum’s first psychotic episode. For Lucy, her mum’s gaming addiction meant that she stopped paying attention to her and her siblings, and was ‘pretty much absent in the emotional sense’, which led Lucy to ask herself ‘how can you sit there and literally ignore your children?’. Lucy described this as having happened during a critical point in her childhood where her mum was her ‘main support system’, and that this change in behaviour had made it feel like ‘she basically just gave up on being a mum to us’. When Lucy was 14 years old, her mum had left suddenly overnight and when she came back weeks later, she started taking medication. This was another change for Lucy. After taking the medication, she describes her mother as ‘a zombie’ and as part of trying to make sense of this change she said ‘I don’t know if it was her psychosis or the medication making her feel like a different person’.

Feeling resentment

It became apparent that Lucy felt resentment towards her mother. When she told a story about her mother trying to influence her university choices, she spoke about the anger she had felt towards her mother for trying to parent her in this respect while she had been so negligent in other ways. Lucy said: ‘why do you get to tell me what to do now when I had to essentially grow up without you telling me what to do?’. In the present, she still held this anger towards her mother. This was particularly clear when Lucy spoke about wanting her mother to acknowledge the pain she had experienced: ‘There needs to be some recognition that this happened in my formative years. And that really screwed me up as a child. And it just makes me really annoyed that you’re denying that my feelings are valid about this’. Her resentment towards her mother was contrasted with the admiration expressed in relation to her father. Lucy saw her father as someone who ‘pretty much took on a single parent role’ due to her mother’s illness. In contrast with her mother, Lucy felt that her father’s presence as a parent validated his expression of opinions about her life: ‘I always had a lot more respect for my dad and his opinions when it came to my life’.

Despite having many siblings, Lucy described feeling alone in her experiences. She gave examples of feeling invalidated throughout her life and described feeling ‘like the only one in the family that ever felt robbed of something’. While Lucy spoke about being able to manage her relationship with her mother better as an adult, there was also a sense of loss and missed opportunity when she says ‘that phase of her as a mother that needs to help me become a human being is over now’.

The enduring struggle to understand

Throughout the interview, Lucy grappled with trying to empathise with her mother whilst reflecting on how hurt she had been by her mother’s actions. This is clear when she says ‘I don’t have children. I think you can never understand what it’s like until you do’. Yet, in the same sentence she says ‘I don’t know how I could ever have mental health issues and completely abandon my children’. Lucy described the hurt this had caused her: ‘It’s impacted me because it was a massive chunk of my life, probably some of the most important years of my life’. She also wondered whether her own mental health problems were related to her childhood experiences: ‘I don’t know if I would have become, in a sense, depressed if that hadn’t happened to me … I can’t really ever know if I would have been fine’. She wondered if there were other negative impacts she was not yet aware of: ‘I haven’t yet unpicked all the ways that it has affected me’.

Being 23 years old, Lucy had only recently entered adulthood. The pain of her mother’s psychosis still seemed quite raw and towards the end of our interview, Lucy acknowledged that she was still reflecting on the impact her mother’s psychosis had had on her: ‘it’s kind of a story in two parts … like what actually happened at the time and how I dealt with it and how I felt about it. And then now like me thinking that it’s kind of over and then trying to unpick what actually happened’.

Salma’s story

Salma is a 25-year-old woman whose father developed psychosis and was given a diagnosis of schizophrenia before she was born, but who had been a constant, unchanging presence in her life. Salma’s parents had emigrated to the UK and she was born here.

Psychosis was ‘our normal’

For Salma, her father’s psychosis was always a part of her life: ‘It wasn’t like we had this normal childhood and then dad fell ill … I literally call it “our normal”’. Salma felt that her dad was in a stable phase with his mental health while she was growing up, and only heard stories from her mother of ‘the experiences she had with my dad when he was very acutely unwell’. Salma’s father also experienced physical health problems, and she reflected on how many of those might have been related to his anti-psychotic medication. Her father’s health meant that Salma, her mother and her siblings all took on caring responsibilities, and Salma had further responsibility placed upon her as a result of her being a child of migrant parents: ‘I was going to appointments with him … and especially because my mum doesn’t speak English so we had that aspect of it as well’.

Identifying as a ‘young carer’ after the fact

Salma’s father died when she was in her late teenage years and it seemed that his death was an essential part of her narrative and a trigger for her in many respects. When she was younger, she felt school was a respite for her ‘because at home it was very centred around my dad’s care’, but that she was not ‘invested in education’. Her dad’s death was a turning point for her in her education: ‘My dad died and then I decided to make something of myself’. After her dad died, Salma’s caring responsibilities ceased: ‘It took away that part of my life. Like we were caring for him and then suddenly we weren’t’. It made her reflect on her caring role: ‘The pivotal moment of realising that I’m a young carer was actually after my dad died’. Another shift for Salma was in her faith: ‘What really helped me deal with it [her father’s death] was the fact that I’m going to see my dad again so this isn’t it’. Before her father’s death, Salma said forgetting to pray did not greatly impact her, but afterwards prayer became ‘a really big deal for me … when we die our children will pray for us and they’ll ask for our sins to be forgiven … praying five times a day meant I could pray for my dad … it really helped me cope’.

Stigma and secrecy

Although Salma knew her father’s diagnosis from adolescence, she and her family were reluctant to talk about mental illness: ‘My mum would allude to the fact that he was ill but she wouldn’t necessarily talk about it specifically as a mental illness’. This secrecy around her father’s mental health also originated from Salma’s community: ‘People referred to mental illness as being crazy’; ‘within the community I come from you shouldn’t talk about things like that’. This might also have fed into why Salma did not see herself as a young carer until much later in life: ‘I don’t think I necessarily wanted that sort of identity when I was younger. I think when you think of young carers you think about people who have parents who are severely disabled and they’re taking care of their physical health’. Her father was also stigmatised by the community for not fulfilling his expected roles: ‘He fell ill and he stopped working. There was this idea that he couldn’t take care of his wider family. He used to send money back home … so there was this idea he could no longer provide’.

Finding purpose through adversity

Salma also received stigma from her community as the child of someone who was mentally unwell: ‘It was the predominant view that we’re all going to go off the rails’. Salma reflected throughout our interview on how she has been shaped by her father’s psychosis and her childhood experiences. She described how it had given her ‘an understanding of not judging people in terms of whatever they’re facing in life’, which seemed especially important to her given how much judgement she had personally faced. Her career path had also been inspired by her experiences: ‘I wanted to, I suppose, help people who are in the same sort of position that I was in’. For Salma, it seemed that this stigma coupled with her father’s death acted as a source of motivation: ‘I wanted to break away from that and show that “yeah my dad was ill, but look at what I’ve done because of that”’.

Hannah’s story

Hannah is a 44-year-old woman whose mother developed postpartum psychosis when she was born. Hannah’s story is a complex one of intergenerational trauma: she spoke of the abuse she had suffered as a child and adult, which resulted in her developing psychosis herself. When talking about the impact of her mother’s psychosis, Hannah did not focus on specific timepoints since it seems from her perspective that her mother’s psychosis has had a consistent impact on Hannah’s life through both child – and adulthood. Hannah recounted that her mother had had ‘12 breakdowns over 18 years’.

A turbulent childhood

Hannah described both of her parents as negligent and her childhood as scary and emotionally cold. She says she knew from an early age that ‘things at home aren’t normal’. She described both of her parents as ‘terrible, terrible drunks’ to the extent that her mother would ‘get really drunk where she couldn’t even focus her eyes on you’. Speaking specifically about her mother, she describes her as ‘the most complex, mercurial difficult character I have ever met and also the most terrifying I’ve ever met at times’. Hannah described how her mother’s mood constantly shifted and how much that scared her: ‘It’s so unpredictable, that’s the scary part […] that you can never tell what she will pick up on. You’ll never be able to predict … what you said or something really innocuous that she will sort of just fly off the handle about’.

When speaking about her emotional attachment to her mother, Hannah talked about never feeling understood by her mother: ‘When I was growing up it was day to day just lack of empathy’; ‘She doesn’t particularly take an interest in who I am or what music I’m into or my feelings.’ Hannah described never truly knowing if her mother’s love for her was unconditional: ‘I’m never too sure if she sort of loves me … because I think it’s very much ‘I love you, I need you, what can I get from you’.

Embarrassment and frustration as a child

Her memories of her mother also focused on feelings of embarrassment about her mother’s behaviour and personal hygiene. She spoke about being embarrassed in primary school: ‘She had black teeth and would not wash very often. And she would have grease and hair down to here so I was really embarrassed in front of the other girls and boys’. In terms of her mum’s behaviour, Hannah disliked her mum’s communication styles: ‘She talks over people so much, it’s so frustrating for me’.

A traumatic adulthood

Her narrative was filled with descriptions of abuse, trauma and grief. Hannah had been in ‘three romantic relationships which have been threatening violence, sort of domestic, you know, abuse’. She’d been in women’s refuges, inpatient wards, and homeless shelters, often feeling very unsafe. Hannah experienced psychosis herself when she was 30. She commented on the stigma of having a severe mental illness: ‘In my experience saying ‘well you know I’m on benefits because of mental health problems’ people run a mile … it’s very difficult to break out of that mental health ghetto’. By ‘mental health ghetto’, Hannah meant when people with certain types of life experiences are grouped together: ‘on housing estates, no money, associating with people with addictions’.

Intergenerational psychosis

Hannah’s family had suffered from intergenerational mental health difficulties. When linking together hers and her mother’s experiences of psychosis, she mentioned that her grandmother had also experienced postpartum psychosis when Hannah’s mother was born. Hannah’s grandmother was ‘put away in an old asylum’ and her mother was ‘sent off to … a lovely Irish couple’. Hannah said that her grandfather had not allowed her grandmother to take medication. When describing her mother’s relationship with her grandmother she said: ‘My mum just didn’t care about her mother. We never visited that grandparents’ house.’ Hannah’s reflections on why she, herself, had developed psychosis presented a complex picture: ‘Part of it could be genetic with me … I think a lot of it is just blinking awful life experiences and I know that’s really the most damning thing for me to sort of say because that’s basically kind of saying ‘oh I wash my hands, it’s not my fault’. But I have had some awful, dreadful sort of experiences’.

Amelia’s story

Amelia is a 45-year-old woman whose mother had two distinct episodes of psychosis during her childhood. Since then, Amelia and her mother have both had further episodes of psychosis.

Confusion and sadness

Amelia recounted some of her mother’s symptomatic expression when she was a preadolescent child, in which her mother would behave strangely, which for Amelia was ‘quite distressing’. Her mother was hospitalised, which led to a period of confusion and sadness for Amelia who described not understanding why her mother was in hospital: ‘I remember crying at school and telling the teacher “I don’t understand what’s wrong with mum. She’s in hospital but I don’t know what’s wrong with her”’. She described how at that age she had associated hospital with physical health, and as a result had reached some extreme conclusions about what might happen to her mum: ‘My guinea pig had died … and I was worried that was going to happen to my mum’. Amelia remembers that the hospital staff thought it best to restrict Amelia’s visits ‘because it was causing us too much distress to see her. But it wasn’t actually … it caused me more distress to not be allowed to then see her’.

A treasured memory after separation

When Amelia’s mum returned home, she was still struggling with her mental health: ‘She was just lying, shaking and crying in bed’. Amelia described how she would look after her mum at this young age: ‘I would cuddle her a lot’. The return of her mum brought Amelia a lot of happiness in her childhood after a long period of separation: ‘I really do remember my 10th birthday party … because it was amazing, my mum was here and able to give me a 10th birthday party because she had been gone for so long’.

Mutually reinforcing mental health

After that, things were ‘normal for quite a long time’ until Amelia was in her teenage years, at which point Amelia’s mother experienced a relapse, and at the same time Amelia experienced her first onset of psychotic symptoms. She describes how from this point onwards her and her mother’s decline in mental health was mutually reinforcing. Amelia describes how her mother became stressed and started experiencing symptoms, and how, in turn, this made Amelia stressed ‘because I have that sensitive and loving kind of connection with my mum’. This resulted in Amelia losing ‘sleep myself because I was worried with what’s going to happen’ until eventually she ‘did actually start to hear voices’. Amelia and her mum were both hospitalised at the same time: ‘I got admitted then to hospital … and then she was admitted because she got really, really stressed about the fact that I had been admitted … I guess she didn’t want me to go through the same experiences that she had been through’.

This cyclical pattern of Amelia and her mother’s mental health and behaviour influencing each other continued into Amelia’s adulthood. Amelia could identify that her mother’s symptoms worsened when Amelia moved away, and she spoke about a time when her mother and father made her mental health worse: ‘Their way of dealing with mental health has impacted very badly on my outcomes … they have moved into my house when I’ve told them not to’. She spoke of her mother interfering with her healthcare: ‘My mum used to phone up the health professionals and tell them my medications weren’t doing anything. I said … “you’re the one that’s making me ill right now mum”’.

Choosing a different approach

Her mother’s experiences of mental health and professional intervention have greatly impacted on Amelia’s preferences and beliefs about managing her own mental health. When Amelia thinks about her mother’s experiences, she is ‘not always convinced that she got the support that she needed … I kind of always associated mental health as something that needed emotional support not just medications’. She had also developed a fear and mistrust of other interventions: ‘She had had ECT and I was really worried they were going to give me ECT. My mum used to talk about it a lot. You know ‘one flew over the cuckoo’s nest … my mum was sitting there going “that’s what it’s like … that’s what therapy is like”’. Amelia recognised this fear herself when she said: ‘Hearing all those distressing things between the age of 10 and 17, it gave me that incredible fear … about what your life could potentially be like if you go to the mental health hospital’. Amelia believed that the intervention in her mother’s life had detrimental effects: ‘As soon as she got diagnosed and labelled she got worse’; ‘I do honestly feel it’s because she’s had so much ECT that it’s affected her ability to learn new coping skills’. This fear led Amelia to hide her psychotic symptoms ‘because I knew that they had tried to diagnose my mum with schizophrenia … I don’t trust people to know what my thoughts are’.

She saw her mother and father as perpetuating this system since they put ‘trust and faith in doctors’ and as being ‘sucked into the medical model’. She saw her parents’ interference as them putting ‘their own little kind of fear bubble onto me’. Amelia’s fear of receiving the same treatment as her mum made her ‘determined to get my degree without the Lithium, without the psychiatrist’. Amelia described her approach to managing her own mental health: ‘I have a more holistic mind, body, spirit approach … rather than just reaching for the tablets constantly’. Amelia sees the contrast between her experiences and her mother’s as stemming from her choice not to use medication: ‘My mum took Lithium and was not well. I ditched it and so stayed clear of this’. Medication has also had another sad consequence in Amelia’s life in that it prevented her from having children of her own: ‘By the time I came off the medications … and had a change in careers it’s a little bit late then for a family’.

Throughout our interview, it seemed that despite both her and her mother experiencing psychotic symptoms, Amelia’s narrative of her mother’s life was one of vulnerability, whereas her own was one of resilience. When reflecting on the differences between her mum’s and her approaches towards psychotic symptoms, Amelia showed great self-efficacy: ‘She can’t get herself back to reality, she seems to be saying ‘I can’t do this for myself’. But I know I can get myself back to reality because I’ve done it’.

Discussion

Four adult children of parents with psychosis reflected on the impact of their parent’s mental health throughout their lives. There was considerable diversity in their experiences, most of which appeared to be due to the point in their childhood when their parent first developed psychosis, and the extent of their parent’s symptomatic expression.

Two participants described their parent’s psychosis as a stable aspect of their childhood, whereas for two participants, the impact of their parent’s psychosis was linked to distinct stages of their childhood. For the latter, their mothers’ episodes caused a shift from a responsive caring mother to a mother who was emotionally and physically absent. There is a lack of research contrasting the impact of parental psychosis on children during different developmental stages, although qualitative interviews with adolescent children of parents with psychosis have described feelings of fear, frustration and resentment (Valiakalayil et al., 2004), with younger children tending to express feelings of sadness and confusion at their parent’s absence (Radley et al., 2023). The child’s developmental stage is likely to affect how easily they can understand their parent’s mental health, as well as the impact that a psychotic episode might have. One participant described, for example, that her mother’s psychosis happened just as she was entering adolescence, a period where she felt she needed her mother most.

Participants’ memories of their parent’s symptomatic expression also varied. One participant for whom it seemed her father had always had a diagnosis of schizophrenia and was symptomatically stable throughout her life, described her childhood as ‘our normal’. She and her family were primarily concerned with managing his health conditions as opposed to dealing with recurrent episodes of psychosis, whereas the other participants had witnessed unpredictable or obsessive behaviour, binge-drinking and extended periods of absence. The most important factor throughout these narratives in terms of the nature and extent of the impact on participants’ lives seemed to be the love and care they felt from their parents. When their parent’s psychotic symptoms and antipsychotic medication resulted in a lack of attention and care, this seemed to have the greatest impact. Two participants described feeling emotionally abandoned by their mother throughout their childhood. One was in her twenties and was still attempting to understand its impact and demonstrated a resentment of her mother due to the emotional neglect she experienced. The other was in her forties, and had suffered greatly throughout life, which seemingly stemmed from her parents’ neglect of her from an early age. Adult children of parents with mental health difficulties have frequently reported an enduring impact on their relationships as well as how they parent their own children (Murphy et al., 2018; Patrick et al., 2019). A lack of parental bonding has been implicated as an important predictor in many emotional and behavioural difficulties in children (Gao et al., 2010; Gladstone & Parker, 2005). Both of these participants had experienced their own mental health problems.

The gender of the parent with psychosis also influenced the impact participants experienced. Three participants in this sample had a mother with psychosis, and for one it was her father. In most cultures, mothers and fathers assume different roles based on gender, which lead to differences such as mothers being less likely to work and more likely to provide childcare (Office for National Statistics, 2019), and fathers being more likely to assume a ‘provider’ role for the family. Because mothers are more often seen as the parent who provides care for their children, they can often face harsher criticism than fathers for not fulfilling this role (Deutsch & Saxon, 1998). Psychosis can undermine a mother’s ability to provide responsive care, and mothers with psychosis have reported feeling shame and guilt about not being a ‘good’ mother (Radley et al., 2022). Similarly, one participant’s father’s psychosis meant he could no longer fulfil the role of provider as he could not work, and as such, faced stigma from his community and the wider family.

A protective factor for children of parents with mental health difficulties is having a second parent without mental health difficulties (Chang et al., 2007). This was clearly demonstrated in the case of the two participants who described how much childcare and housework the other parent took on as a result of one parent’s experience of psychosis, and how much they respected them for this. However, for one participant both of her parents experienced mental health problems and substance use, meaning her home environment was particularly unstable. It is important to note that despite a second parent mostly being a protective factor, people with prior psychosis are more likely than those without psychosis to have a child with someone who also experiences a serious mental health problem (Greve et al., 2021; Ranning et al., 2016).

The ways in which the participants’ parental psychosis impacted on their adulthood ranged from resentment, trauma and mental health problems, to being able to learn from their parent’s struggles. Three participants spoke about their own mental health difficulties, two of whom had experienced psychosis themselves. One participant who had developed psychosis used her learning from observing her mother’s poor experiences with services and treatment to increase her control of her own mental health, with as little reliance on medication as possible. Another participant described how witnessing her father’s mental health problems had inspired her to pursue a career in which she could help others with similar difficulties, which is a common reason for career choice within healthcare professionals (Murphy & Halgin, 1995).

Strengths and limitations

A strength of this study is that it highlighted both risk and resilience factors in the context of parental psychosis rather than having an overwhelming negative focus. Using a narrative methodology allowed this study to capture participants’ perspective of the impact of their parent’s psychosis over time as well as in the present day. A limitation is that every participant identified as female and it is possible that male children of parents with psychosis may have different experiences and perspectives.

Implications for practice

These findings demonstrate the importance of recognising the potential for poor mental health outcomes amongst children of parents with psychosis. When practitioners are working with a service user who is experiencing psychosis, and is also a parent, it is essential that they work with this service user holistically. They can do so by considering the needs of the service user as a parent as well as the needs of their family. Increasing attention is being paid to developing holistic interventions, such as Let’s Talk about Children (Maybery et al., 2017), which aims to support parents to speak about their mental health difficulty with their children. Parents presenting to services presents a unique intervention point to work with their children by signposting them to relevant organisations and even preventative interventions which could provide coping skills to help foster resilience against poor mental health outcomes.

Conclusion

This analysis of risk and resilience narratives amongst the children of parents with psychosis have highlighted a number of factors which can affect the impact of parental psychosis. These included the age of the child when their parent first experienced psychosis, the symptomatic expression including the presence of positive psychotic symptoms as well as the presence of a second parent or another adult in the family who did not experience serious mental health difficulties. Therefore, when parents present to services, it is essential to consider not only their needs, but the needs of their children too in order to prevent them from experiencing future poor mental health outcomes.

Reflective statement

It was important to acknowledge how in qualitative research, themes are generated through the lens of the researcher which is influenced by a range of factors including their culture and values. As the primary researcher, I tried to actively acknowledge these factors during the study and maintain curiosity about why we paid attention to particular parts of participants’ narratives.

Although some understanding was shared, participants varied in terms of their exact understanding of what ‘psychosis’ is and whether they ascribed to a more Western ‘medical model’ view of mental health or not. We thought it was important to acknowledge this difference while trying to maintain the common thread that was shared between all participants.

The use of narrative analysis made it possible to tell participants’ stories of their parent’s psychosis, and what meaning they attached to their experiences. These narratives were reported at only one timepoint in participants’ lives. One of the participants in her twenties was reflective about how she felt she was only just starting to fully understand the impact that her mother’s psychosis has had on her, and had only recently realised that her childhood, and the period of her life where her mother should have cared for her, was over. It is likely that all four participants will go on to reframe and reshape their stories of their childhoods and their parent’s psychosis.

Disclosure statement

The authors report there are no competing interests to declare

Data availability statement

The data are not publicly available due to privacy or ethical restrictions.

Additional information

Funding

During the undertaking of this research, Jessica Radley was a DPhil student and was funded by Mental Health Research UK. The research activities received no other external funding. This study has also formed part of a DPhil thesis.