Copyright 2004 by Sharon Smith, PsyD

Summary of Review of Literature

Deinstitutionalization changed the locus of care for most individuals with serious mental illness from state institutions to the community, where families often shoulder the caregiving responsibilities. Among the categories of family members who attempt to help the ill individual, one that has heretofore received little attention is adult children. Some adult children who are currently in a caregiving role for a parent who has a schizophrenia-spectrum disorder were raised by that parent. Possible effects of childhood experiences of parental illness on a current caregiving relationship between the adult offspring and the ill parent have been to date only tangentially explored.

The focus of this project was the exploration of the perceptions of adults raised by a parent with schizophrenia (APS) about the effects of childhood experiences on a current caregiving relationship with the ill parent. In this investigation, APS who currently considered themselves to be in a caregiving role with the parent were asked to discuss that role, any perceived origins of that role in childhood, and current conflicts between fulfilling their perceived responsibilities to the ill parent and to other family members. They were also asked for their views of the effects of their parents' illness on current caregiving efforts. Themes identified in prior work are explored, including ongoing resentment of the ill parent (and other family members) for lack of appropriate nurturance in childhood and adolescence; grief for loss of a "normal" parent-child relationship; and strong desire to parent their own children better than they themselves were parented.

These and several other issues mentioned in prior literature arose in participants' narratives. They discussed, for example, the parent's resistance to receiving appropriate care, frustration with both public policy and clinicians (e.g., a valuing of psychotic patients' civil rights over their right to receive appropriate treatment; the role of confidentiality in preventing vital communication with professionals treating the parent; and clinicians' lack of information and insight into APS's existence and needs, in both childhood and adulthood).

A philosophical assumption of qualitative research is that "knowledge is within the meanings people make of it" (Creswell, 1998, p. 19). The results of this study may help APS who have suffered from an unpleasant or painful sense of the stigmatizing uniqueness of their situation to find, in this discussion of concerns similar to their own, the comforting sense of universality that Yalom (1995) has referred to as a "welcome to the human race" experience (p. 6). In addition, exploration of APS's experiences and beliefs is expected to be generally helpful to clinicians who work with them (Caton, Cournos, Felix, & Wyatt, 1998; Dunn, 1993; Klein, 1990; Marsh & Dickens, 1996b, 1997; Marsh & Johnson, 1997; Williams, 1998).

This study also has potential to inform psychologists' efforts to address problem areas already noted in the literature. It aimed, for example, to increase therapists' awareness of family burden and the importance of reducing potential conflicts between client and family (Hatfield, 1997; Nicholson, Geller, & Fisher, 1996); to ensure that the parenting status of patients with serious mental illness is noted in their charts and attended to in treatment planning (DeChillo, Matorin, & Hallahan, 1987; Mowbray, Oyserman, Zemencuk, & Ross, 1995; Nicholson, Geller, & Fisher, 1996; Rutter, 1994; VanHaren, LaRoche, Massabki, & Colle, 1993); to view APS as individuals with needs of their own who happen to provide care for an ill parent (D. L. Johnson, 1994); to be aware of themes that might be expected to arise within APS's own psychotherapy, such as combinations of loyalty to the ill parent with guilt for growing up and moving out (Dunn, 1993) and possible difficulties parenting their own children (Williams, 1998), and to encourage clinicians to increase their awareness of the rapid advances in treatment that have occurred in recent decades(Shea, 2002).

Research into the caregiving experiences and perceptions of APS has potential to inform policy and program development for individuals with serious mental illness and their families (Caton, Cournos, Felix, & Wyatt, 1998). Specifically, it may shed light on areas already depicted in the literature as problematic. Examples include caregivers' interactions with the service delivery system in general(Marsh & Johnson, 1997; Torrey, 1995b); pre-discharge planning for hospitalized patients and case management for patients in the community (Wegner, 1990); managed care companies' decisions regarding payment for family psychoeducation (Lefley, 1994); public funding for provision of a support system for parents who have schizophrenia (Mowbray, 1998; Nicholson, Geller, Fisher, & Dion, 1993, Nicholson, Geller, Fisher, & Dion, 1993b; Sands, 1995); and ways in which psychologists may work to reduce social stigmatization of families in which a member has schizophrenia (Lefley & Wasow,
1994).

Overview

This section provides an account of factors and themes that emerged from the analysis of the narratives of adults raised by a parent with schizophrenia (APS). APS's voices are often heard here, depicting their experiences and perceptions in their own words. While interpretation and speculation were inevitable in the process of selecting and ordering exemplars, the main thrust of the section is description. Description provides a sense of the relationship among variables I have tentatively identified within each axis, and also permits the reader to trace my steps from the transcripts to some hypotheses that will be offered in the general summary.

The project's goal was to reveal APS's experiences and perceptions by presenting exemplars in each relevant area. This chapter describes both the process of collecting and analyzing information and the patterns or themes which emerged in participants' narratives. The guiding research question was "How do APS perceive any effects of their childhood and/or adolescent experiences with the ill parent on their current efforts to provide some level of care for that parent?" To answer that question, I collected data in three broad areas: participants' childhood and adolescent interactions with the ill parent and other family members; their current involvement with the ill parent and other family members; and their perceptions of the effects of the former on the latter. The information in this section came from APS's responses to the Background Questions and Probes. Each participant chose a code name to which his or her responses to my e-mails would be attributed.

Numerous themes and concepts arose in the course of e-mail dialogues with participants. I used qualitative research software to organize them in ways that encouraged systematic and comprehensive analysis through the course of a flexible data collection process, and permitted differences of opinion to emerge and be noted. When all participants' data had been collected and analyzed, a peer audit was used to determine the fairness of the research process and the accuracy of my findings in terms of internal coherence. After the data were analyzed, the research questions, though valid and useful as starting points, came to appear limited in scope. Analysis of data revealed a cornucopia of APS's experiences and perceptions.

Data Analysis

Initial Steps
I maintained a process and progress log throughout this study. The following information comes from that log. Nine of the 11 participants joined this study within the first five days following its advertisement, and the last two joined the following week. Thus, for the most part, e-mail dialogues evolved simultaneously. Each time a message arrived, I read and reread that individual's transcript (a collection of e-mails arranged in chronological order, along with my own responses), in order to situate the incoming information and my reply within the participant's personal narrative. I summarized each person's newly arrived information in my own words and started my reply with the summary, inviting the participant to let me know what I was correctly understanding or misperceiving of their experiences and insights. In addition, I asked at least one new question. Participants readily grasped this process, and sent back copies of my message with their own comments interwoven (e.g., "Actually, I think it was my elder sister who told me the diagnosis. She was 12 at the time"). When they responded to my new question(s), the process repeated.

I roughly presorted data in three ways, using the QSR software program for analysis of qualitative data: by topic (e.g., all participants' responses to the background question "please BRIEFLY describe your parent's symptoms. . ."); by participant (e.g., a checkoff indicating which "probe" topics remained to be asked of or clarified by a given individual); and by demographic information (background data entered into a spreadsheet program). Once the majority of participants' pre-sorted files were about 75% complete, I read all interview transcripts through at once, to gain an overall sense of APS's experience, and to note phrases or sentences suggestive of emerging topics and themes. As expected, the data did not fall into neat categories. Many potential links between different parts of discussions or observations came to mind, and were entered in a file of their own.

I then reread the files and copy/pasted excerpts into new files organized by theme (e.g., "feelings toward ill parent"), to identify key topics and issues in each text. Theme files were then perused individually and as a whole, so that excerpts could be reassigned and themes regrouped as new data continued to arrive. I validated thematic clusters daily by following their codes back to the interview transcript to determine if the clusters omitted any information or conveyed anything not present or implied in an individual's transcript. I used my "themes" list as a set of points with which to ask questions of the narratives, and summarized each of them.
A dozen or so themes were emerging in some participants' narratives but not in others, so I developed a new set of files in which to pre-sort them by topic and by participant as above, and began inquiring about these topics in each ongoing dialogue. As before, I provided my own "take" on new information, and participants responded with assent and/or clarification. The quest to identify relationships among the various themes and concepts in APS's narratives begins in the sections that follow.

Responses to the Core Question

As noted earlier, in response to direct questions every participant reported that his or her parent exhibited behavior consistent with a diagnosis of a schizophrenia-spectrum disorder while the APS was growing up. In addition, there were spontaneous reports of other parental behavior, including positive interactions, various types of abuse, and neglect. I tentatively abridged and combined sentences and phrases from our ongoing dialogue with what each person had initially written in response to the core question; then I e-mailed this to each participant for review and made the changes they suggested (Appendix U)

First, I analyzed participants' responses to the core question ("How do you perceive any effects of your childhood and/or adolescent experiences with your ill parent on your current efforts to provide some level of care for him or her?") in terms of the APS's current feelings toward the parent and the type of care he or she provides for the parent. As I reread all participants' full narratives in the context of these categories, a set of labels emerged that were roughly descriptive of the APS's current feelings (yearning for parent's love, love for parent, hope for closeness) and caregiving efforts (frequent contact, support, duty). Each label had an obverse, e.g., lack of yearning, hatred, hopelessness; lack of contact, nonsupport, motivation other than duty). I did not further refine these labels (e.g., develop criteria for small, moderate, and great frequency of contact), because their statistical significance was not an issue due to the small number of participants in this study.

Next, I studied the APS's examples of the ill parent's caregiving behavior toward them in childhood and adolescence, and the APS's recollection of their own feelings during those years. Tentative patterns emerged, but also important exceptions to the patterns. These will be addressed in the Discussion section. To gain greater understanding, I also encouraged participants to explore a number of topics and themes that my reading of the literature suggested might have influenced their then-vs.-now relationships with the ill parent. Following a brief introduction, the results of this process will be explored through the lens of Bernstein's (2000) three-axis heuristic: Brain, Context, and Developmental stage.

Analysis of Narratives

Overview

Participants' narratives strongly suggest that these APS were at substantial risk as children and adolescents-and that they have experienced widely varying types and amounts of support across the years. This study employs a developmental perspective in order to place each individual's behavior in relation to both internal and external contexts (Sameroff, 2001). Specifically, Bernstein's (2000) theoretical framework of pediatric risk assessment--brain, context, and development--is utilized to organize the data for closer examination. Within this framework, the effects on children of being raised by a parent with a schizophrenia-spectrum disorder can be examined in terms of the child's genetic loading for psychopathology, the child's social context, and his or her development from infancy into adulthood.

Brain Genetics

Bernstein (2000) describes the construct of "brain" as simultaneously a dependent and independent variable. Applied to APS, this construct would comprise two concepts familiar from the risk-and-resilience literature: the possibility that a child's brain has a structural and/or neurochemical predisposition to mental illness, and the child's intelligence. Brooks (1994) specifies "higher intelligence, and more advanced problem-solving skills, cognitive-integrative abilities, social skills, and coping strategies" (p. 545).

It is undisputed that genetic factors are involved in the transmission of schizophrenia-spectrum illness. While the precise mechanism of transmission remains a matter for genetics researchers to untangle, the diathesis-stress model suggests that the behavioral expression of any biological vulnerability for schizophrenia must be triggered by exposure to stress. However, considering the variety and possible combinations of criterion-meeting symptoms, most questions about etiology are unlikely to be answered soon.

The prevalence rate of schizophrenia in children who have one parent with schizophrenia is 12% (Kaplan, Sadock, and Grebb, 1994). All that can be safely stated of participants in this study is that since all had at least one close relative with schizophrenia, they, their own children, and their siblings may be assumed to be at higher risk of serious mental illness than the general population. One man, for example, has two sisters and a brother who have schizophrenia. One woman's son has schizophrenia. One participant reported that she herself has been formally diagnosed with schizophrenia. Estimation of the balance of participants' risk with constructs such as resilience was outside the scope of this study.

The one participant who has been diagnosed with schizophrenia reports that her initial assumption was that her own symptoms of schizophrenia were caused by living with her very ill mother. This notion appeared to be borne out when she moved farther away from her mother, and her own symptoms subsided: ". . . they were pretty mild most of the time. Mostly, I had visual hallucinations, but I heard voices sometimes too." Several years later, when she moved closer to her mother, "Right off the bat, I started having really bad symptoms. They would increase in their intensity whenever I was around my mom. I was hospitalized the first time when I was about 34." Since then, she has been stable on medication and sees a therapist regularly. She notes, "It took a while to discover that sz can be a heritable condition. I still had abuse issues to deal with, but could no longer blame my sz on my mother." No participant spoke of blaming or being angry with the ill parent in the context of genetics, though all participants--and their children-are at higher risk than the general population. Rather, several hold the parent culpable for his or her often-abusive behavior toward them and other family members.
Intelligence.

The second concept under the rubric of "Brain"--familiar from the risk-and-resilience literature--is intelligence (cf. Werner, 1989); this of course overlaps with "Genetics." Although compilation of hard data on participants' level of performance in the realms Brooks (1994) lists was beyond the scope of this study, it was possible to surmise intellectual level in individuals who mentioned their academic or professional achievement. One had a year of college. Two were full time college students: One was taking premed courses. Two had graduate degrees and worked in professional fields. One woman was vice president of a corporation. Nevertheless, there was no way to estimate or compare participants' intelligence, or to correlate it with any other factors. For example, APS's ability to obtain a college degree or professional career may have been affected by nonintrinsic factors such as lack of money for tuition, lack of family support, or the presence of cultural mandates which discouraged or proscribed higher education or careers for individuals of their gender or race (e.g., Bachrach & Nadelson, 1988).

One woman emphasized the importance of support from her teachers: ". . . at this time [adolescence] I was doing quite well in my school and got the support of a lot of my teachers, . . . none of whom knew abt mom . . . and I used to get a lot of appreciation for my activities . . . I am [now] a psychiatrist by profession." As we learn more about her journey from rage and alienation to loving acceptance of her mother, her intelligence will continue to be in evidence, along with the self-esteem she gained by doing well in school.

Context Overview

I have discussed certain APS in relation to the internal construct of "Brain." Now, still working within a developmental perspective, I will examine APS through the lens of the construct called "Context." Mowbray (1998) notes that a parent's diagnosis "does not appear to consistently predict the level or the nature of the behavior or performance problems that children have" (p. 12). She emphasizes the likely role of the child's and family's context as a set of intervening experiences.

Context is a topic on which participants provided detailed information, as the stress and concern associated with chronic psychiatric illness can give rise to serious family problems. A family may live from crisis to crisis, becoming ever more baffled and bewildered by the parent's illness. In such circumstances, children's needs may be postponed or neglected altogether. A child or adult's context can include not only home and school environment, but also psychosocial factors such as culture/ethnicity, socioeconomic status (SES), parental behavior, and the presence or absence of a supportive extended family and/or community.
Culture/Ethnicity

Most participants did not discuss the role of culture or ethnicity. The exception was a Hindu woman in India. In her culture, she notes, family members are intimately involved in one another's lives. ""Parentification' isn't technically known to exist or taken note of [in India]... it just is... it is the done thing... the accepted thing for young children to take over "parent" roles within an extended family." For example, "during [a psychiatric inpatient] admission, [a relative] would live in with the patient and would participate in day care and in giving meds etc." Although her mother does not require hospitalization, much in-home family support has been necessary over the years. Only in the past three years has her brother "felt secure enough to pursue his career in another country with his family." This daughter notes, "bit by bit I have started etching out an independent life and have managed to make a lot of room for myself within our family and society." For instance, although she continues to live at home, her profession as a psychiatrist requires her to work some nights and 24-hour shifts every week. For convenience, she rents a small room near the hospital where she practices. She reported that, after years of struggle with her mother's symptoms, "As a family we are much closer and better adjusted than ever before."

Socioeconomic Status (SES)

As the risk-and-resilience literature attests, socioeconomic status has potential to affect families in which a parent has a psychiatric illness. A downward spiral of reciprocal effects may occur, in which impairment across functional and occupational areas of life leads to ever lower socioeconomic status and residence in marginal neighborhoods (e.g., Aro, Aro, & Keskimaki, 1995). These factors, in turn, provide additional stress for the parents and children alike. In the current project, several APS reported that the well parent, or other family members, managed to provide a good living for the family, often against great odds. Some ill parents had spouses who managed to provide a good living. When participant was a child, the family was "rather poor . . . . there wasn't much money to go around, much less money for psychiatric care." Yet as time went by her father managed to pursue a career in real estate, while providing what amounted to full time caregiving to his wife, though at tremendous personal cost. One well father was a physician, another was a career military officer. While both describe emotional disarray in the family while they were growing up, this was apparently not compounded by indigence.

Symptoms and Course of Parent's Illness

Also found under the rubric of "context" is the transactional process of severe mental illness on parent, and child, as they engage with each other in the context of waxing, waning, or chronic symptoms of psychiatric or comorbid illnesses. Contextual factors are sometimes neutral or benign. Yet it is well known that they can also be lethal: every year, children are harmed or even killed by a parent in the toils of a florid psychotic episode. Mowbray (1998) emphasized that parental diagnosis, per se, fails consistently to predict the outcome for children. Based on the narrative reports of APS in this study, it appeared that day-to-day parental behavior, rather than a list of symptoms that meet criteria for diagnosis, would be a more useful concept in this regard. For this reason, the concept of "symptoms," as used here, also takes in the parent's non-illness-related behaviors, such as abuse or neglect, and positive interactions between parent and child.

Earlier, I noted that all participants described their ill parents as suffering from an aggregation of symptoms consistent with a schizophrenia-spectrum disorder. Their narratives provided a finer-grained delineation of the child's "context" of parental behavior than do most research articles. Positive symptoms included paranoia, delusions, and hallucinations. For example, after one father crashed his truck, he was:

Very paranoid, said people were chasing him, and that he got away . . . . All the way home, he told my bro to watch what he says and does due to the fact 'people' will come after them and try and kill them. . . . He even thought one time that I was going to cut his throat . . . . He also thought the food was poisoned, he went without eating for 14 days one time.

One ill father may have had a delusion that his wife was unfaithful, as his daughter reports he would "accuse [Mom] of being somewhere where she wasn't, and accuse her of dating other men. Which all was not true. She had to watch every move she made, he was very controlling."

Another describes her mother's ". . . strange ideas. She once threw all our books away because the house got too heavy." Another mother "sees the world as a sinful, hostile place." When seriously ill, another developed a delusional process in which her daughter had a role as persecutor. One mother "had the television turned so the screen faced the wall. She was telling [my sisters] she didn't want us to watch television any more because the devil was coming out of the TV." Another "told us crazy stories such as being a member of the British royal family who was abducted as a child."

Most parents were described as having hallucinations. One "claimed that messages were being sent to her through 'voice boxes' by the government." Another "Heard voices, talked to herself [and] looked at herself in the mirror while talking to the voices." The latter mother also had visual hallucinations, and "told us [children] our faces were mutilated by bad people during infancy." Although one APS's mother "never told me that she heard voices until I was older," she often "laughed without any motive. She called that being 'secretly amused.'"

One participant's mother had olfactory hallucinations, and "would swear she smelled ammonia coming from the garage [below their apartment] and that the people downstairs were trying to poison her. She would yell and scream through the walls at them." Another's father "thought people were pumping gas into the house, in the middle of winter he had the doors and windows all open."

Several parents were reported to have negative symptoms of schizophrenia, as well. Negative symptoms can include anhedonia, poverty of speech production or content, lack of emotional expressiveness, catatonia, and avolition. Sometimes included in this category are emotional withdrawal, asociality, motor retardation, inappropriate affect, and impaired attention.

One woman's mother suffered from catatonia in addition to paranoia and delusions. Another woman spoke of her mother's "lethargy, inability to find pleasurable things to do," as well as her "paranoia, delusions, [and] agitation." A man whose mother has been institutionalized for decades with a diagnosis of paranoid schizophrenia depicted his childhood home with her as "a total pigsty". Another APS explained that, for a few years after her mother's psychotic break her major symptom was "the loss of affect." Though she went through the motions, "she simply had no notice of her children's cognitive, emotional, bonding needs." This daughter noted that "As the years went by the neglect and inattention increased."

The course of parental illness was variable: some afflicted individuals' illness followed a static course, while others experienced a series of relapses and remissions. The ill parent's spouse and children were likely to experience feelings of sorrow and bereavement, both at the onset of illness and as it progressed. A steady downward course had potential to be discouraging. Yet a relapsing/remitting course could make it difficult for family members to deal with their feelings: they might come to terms with one puzzling or dangerous set of symptoms, only to discover new ones unexpectedly arising.

Several participants stated that the parent's symptoms followed a steady or downhill course. After one man's mother became ill, when he was seven years old, she regressed to the developmental level of a "six-year-old" and remains at that level to this day. Another person's mother has never had a remission. Most APS, however, described a relapsing/remitting course. Another mother has gradually improved in the past five years; her daughter attributed this to medication compliance and "an increased awareness and openness within our family about her illness and how to handle her outbursts . . . with less emotional reaction and more calmness. . ." Another participant also attributed her mother's pattern of stability and relapse to taking medication "about 27 years, with every once in a while a stop. With all the consequences." To her great frustration, her mother recently stopped taking her medications.

One mother had severe depression with psychotic features and "although [she] had a few weird periods when I was little . . . managed to stay out of MH facilities .. . ." One participant noted that "a combination of late onset [of his mother's illness], supportive family, and the ability to escape helped save me." His mother experienced "periods of relative wellness interrupted by relapses [for many years]. . . ." For the past five years, though, she has been in a "permanent mild psychosis." One mother enjoyed a long remission during which she worked as a teacher. But when her child was about fourteen, the mother lost her job and had a relapse. This APS's own psychotic break occurred at about this time--a coincidence which, as noted above, she took as proof that her illness was not biochemical in origin but the result of enduring the stress of her mother's illness.

One woman was uncertain how old her father was when his schizophrenia began, or of its course. He abused alcohol from his adolescence through adulthood; when hospitalized for a stroke in his early 50s, he was formally diagnosed with schizophrenia, the onset of which was said to have predated his alcoholism. This diagnosis made sense to the family in light of his paranoid statements and behavior over many years. His symptoms "grew worse after [his] stroke, but [he] is much better now . . . no episodes in two yrs" on his present medications.
Comorbidities

In addition to their symptoms of schizophrenia-spectrum illness, several parents reportedly developed one or more medical conditions. Alcoholism and abuse of other drugs can have a relatively early age of onset; physical injury and cancer can strike at any time. Among these participants' parents, illnesses such as anorexia, stroke, dementia, and sequelae of brain surgery occurred some decades subsequent to the schizophrenia symptoms described above. For example, about four years ago, one mother, who was in her 70s at the time of this study, sustained a soft tissue injury to her back that added difficulty in walking to her (and by extension, to her son's) life challenges.

One man reported that his father-in his seventies- was "in far better physical condition than most forty-year-olds." Other parents of APS in this study were not so fortunate. One's father was "a very bad alcoholic," though recently her "bro figured out [their father's paranoia] was probably the illness working on him and not just the alcohol." Another's mother, in her 50s, had cancer. At age 52, one father had a stroke. His physicians "kept saying it was blood clots in his brain that was doing that, but I didn't believe them. . . . Of course eventually the drs finally diagnosed him [with schizophrenia]." She now provides total home care for him. One parent, presently in her sixties, was diagnosed with a malignant brain tumor six or seven years ago, and became aphasic following surgery and chemotherapy.

While their parents' substance abuse and new-onset medical conditions contributed to the challenges APS face-such as caregiving burnout--to some degree they may also have served to normalize the parent's behavior in the eyes of a society that has adjusted to relative openness about a parent's drinking or dementia. One APS's mother, for instance, was in her eighties. A few years ago, she had a mild stroke, her second one, adding dementia to her list of cognitive symptoms. The daughter reflected on differences between a "normal" dementing parent and a dementing parent with premorbid schizophrenia:

. . . when it starts to come to dementia, it is 1) hard almost to separate one from the other since a lot of the behavior is so similar and 2) hard to be sympathetic about the dementia since we're all so darned fed up with the whole sz thing. However, I believe that for a "normal" parent, those kids would be truly worried and feel bad, etc. because they know it's "only dementia" and have had an otherwise normal life . . . the offspring aren't buying the sympathy part and the regular families are. . . . If you tell people your mom has Alzheimer's, it's ok. If you tell people your mom has sz, their eyes glaze over.

Tangentially Illness-related Parental Behaviors

Of course, not all of an ill parent's behavior is directly related to psychiatric or medical illness. For the purposes of this study, it was not necessary to untangle possible roots of any given behavior. Some parental behavior consisted simply of garden variety parenting-positive interactions and nurturance. In the face of serious and chronic psychiatric illness, a number of parents did provide their children with sufficient nurturance to create a permanent and positive emotional bond. One APS recalled that, prior to her illness, "My mother read to me. She taught me to read. She played card games with me. She was my beloved friend." One mother's brief interludes of remission and insight, which made her agonizingly aware of all they both had lost, did grant her mother opportunities to apologize for her conduct. Initially, "that was extremely confusing for me . . . and then extremely painful and emotional." Over time, though, this woman decided that her mother's erratic behavior during her "bad times" was not her "inherent self." Such an ability to accept that a parent's behavior is a function of illness rather than any deficiency in themselves or parental malevolence can be an important factor in healing.

In order to avoid priming APS with the notion that parents who have schizophrenia are abusive, none of the background questions or probes asked for examples of abuse. However, a number of participants spontaneously reported that they were abused and/or neglected while growing up. Although the literature on child offspring of parents with schizophrenia is rife with stories of abuse, one woman complained,

My mother's current shrink repeatedly says that violence is no more prevalent among schizophrenics than in the general population. I believe he is referring to those that end up as news headlines, like Andrea Yates. I believe he is clueless as to how much abuse is committed by sz's toward their children.

Continued - Go to Part 2 - The Longest Bereavement