Pregnancy is a challenging time for the patient with psychosis, the fetus, the psychotherapist, and the team treating the patient. Little is known about being a parent with psychiatric illness and how to manage this clinical situation. This paper is the sequel to a previously published case study that described the process of psychotherapy with a schizoaffective patient (See AJP 62/2, 35-49). The patient became pregnant and gave birth to a boy. This paper reports the psychotherapeutic process of the patient during pregnancy, the child's early years, and over ten years after childbirth. The process of psychotherapy is discussed.
KEYWORDS: motherhood; mother-infant psychotherapy; psychotic mother; schizoaffective mother
The process of deinstitutionalization has had unexpected consequences on the sexual and reproductive lives of people with severe mental illness. Patients with severe mental illnesses, such as schizophrenia or other psychotic disorders, aspire to a "normal" life in the community. As Miller and Finnery (1996) pointed out, the impact of deinstitutionalization has been particularly significant for women, who had fewer and shorter hospital stays than men with the same diagnoses: women were more sociable, more likely to date, to cohabit, and finally to engage in a sexually active life (Miller & Finnery, 1996). Consequently, the proportion of severely mentally ill people who are parents has been reported to be increasing, although it remains lower than in the general population (McGrath et al., 1999; Oyserman et al., 2000).
Women with psychotic disorders have more children and a more active parenting role than do men with similar diagnoses (Test et al., 1990). In a study of patients with psychosis in London, 63% of women, but only 26% of men, had at least one child (Howard et al., 2001) and in Australia, McGrath and colleagues found that 59% oí their female patients were parents, compared with 25% of men. However, losing custody of a child is a frequent problem encountered by patients (Coverdale et al., 1989). Kumar et al. (1995) reported that 50% of mothers with schizophrenia were discharged from the hospital after giving birth without their babies, and Howard et al. (2003) found that 48% of mothers with schizophrenia and their babies were supervised by social services after discharge.
Litde attention has been paid by adult psychiatry in research and service development to the fact that a severely mentally ill patient can be a parent (Howard, 2000). Yet it seems that motherhood, childcare, parenting, and having a partner have an impact on the course of women with schizophrenic and schizoaffective disorders during the first postpartum year (Bosanac et al., 2003). Moreover, the general assumption that psychotic patients are alone or with their parents and do not have families of their own, are based on stereotyped expectations, as are the services offered (Oyserman et al., 2000; Diaz-Caneja & Johnson, 2004).
Experiences of being a mother with a severe mental disorder have been examined in a few studies in the United States, Australia, and the United Kingdom. Most of the mothers studied reported great joy, fulfillment, and a sense of confidence in their parenting skills, but also described stress due to economic difficulties, lack of social support, fear of relapse, fear of children being stigmatized by the illness, and fear of losing custody of the child (Mowbray et al., 1995, 2001; Diaz-Caneja & Johnson, 2004). Additionally, women reported difficulties in combining medication and the concentration needed in caring for children. Mothers worried about the impact of their illness on the mental health of their children (Diaz-Caneja "Johnson, 2004). When interviewed, most women made it clear that they felt strongly involved in motherhood and did not want to relinquish their parental rights, although the rate of custody loss is high (Miller & Finnerty, 1996). …