Women with serious and persistent mental illnesses often have hard lives. They usually have experienced significant trauma during their childhoods. They are far more likely than those without mental illness to be homeless at one time or another, and life outdoors takes a toll on the body and the mind. They are more likely than other women to be victims of crime, particularly assault and rape, which also take a terrible toll on body and mind. Many abuse drugs at some point during their lives, with consequent risks for malnutrition and communicable diseases such as HIV/AIDS, hepatitis, and sexually transmitted diseases. They are also likely to live in poverty, struggling to make do for themselves and sometimes their children too with income from Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), and food stamps.
These are not the only reasons, but they certainly are among the most important reasons, why women with serious mental illness have poorer health and die considerably younger than women without serious mental illness.
Many women with serious mental illness also experience the deep disappointment of having their children taken from them to be raised by other people. Sometimes this is necessary to protect the children from a mother who simply cannot manage the tasks of parenthood or, on rare occasion, because the mothers are made dangerous by their hallucinations or delusions. But often these mothers lose their children because the child welfare system tilts towards removal without adequate understanding of the difference between being mentally ill and being dangerous. As a result, many women with serious mental illness who have children avoid contact with the mental health system, fearing that they will be reported to the child protective service and that they will then be stripped of what is absolutely most important to them.
These facts have been known for many years, and I wish that I could say that our health and human service systems have responded appropriately. But the truth of the matter is that the mental health, physical health, substance abuse, child welfare, education and other service systems have not done well by women with serious mental illness.
What Should Be Done?
Address Childhood Trauma: The negative impact of childhood trauma on adult life is hardly news, and from time-to-time during the 20th century preventive efforts were made, sadly with very limited effectiveness. A recent study on the impact of “adverse childhood events” has given new impetus to the hope for prevention. Both at the federal and state levels, there is talk about the importance of building emotional strength—sometimes called “resiliency.”
But will effective action be taken? It will cost money I am sure, and there seems to be a political consensus (not to be confused with an empirical reality) that our society cannot afford to spend as much as we do already on human troubles. In addition, it is not at all clear that there is a preventive technology ready to go on a wide scale.
Prevent Homelessness: Again, this is a need that has been recognized for a very long time, and there has been real progress in the development of housing for homeless people. But it has been slow, leaving many people out. Much of it is now on hold for fiscal reasons. And supportive housing for women with serious mental illness with their children is rare.
Reduce Crime: Protecting women with serious mental illness from assault and rape without violating their rights to liberty in a free society is exceedingly difficult. What is particularly distressing, however, is that this has never been a priority for our mental health system. Safety, it seems to me, is a precondition of recovery. The risk of being a victim needs to be taken far more seriously than it has been.
Reduce Co-Occurring Serious Mental Illness and Substance Abuse: This, of course, has been a priority of the mental health and substance abuse systems for a very long time. Some progress has been made, but not nearly enough. What is needed is integrated treatment for people with co-occurring disorders, something there is far too little of. And it is not at all clear that merger of the two service systems—again under discussion—would do anything soon to increase the availability of integrated treatment.
Improve Health Promotion and Health Care: Happily, this does seem to be a high priority for the physical and behavioral health systems at both state and federal levels. Health care reform includes an emphasis on both integrated care and prevention via “medical homes,” “health homes,” and “accountable care organizations.” Let’s hope that some of these organizational experiments are effective.
Reduce Poverty: Poverty may be the single most important determinant of poor health and mental health, but maintaining people with disabilities in poverty is the core of our society’s policy with regard to disability. That may seem a strange and harsh way to characterize the policy, but sadly income maintenance payments and food stamps do not raise people out of poverty or remove them from its risks.
Change Child Custody Laws and Practice: Without doubt, our society needs to protect children from parents who seriously neglect or abuse their children; and without doubt, parents with mental illness are sometimes guilty of abuse or neglect. But so are parents with many other kinds of illnesses that may from time-to-time make them incapable of being adequate parents. Yet, there is nothing in law to suggest that diabetes, obesity, cancer, Parkinson’s Disease, etc. may be the cause of child maltreatment. Language in the law that singles out mental illness as a cause of child maltreatment should be removed. In addition, child protective service workers need to be helped to distinguish between a parent who is dangerously mentally ill—quite rare—and a parent with mental illness who is not dangerous to her (or his) children. Here’s an action that could be taken at very little cost that might have a great impact on women who avoid getting treatment because they are afraid of losing their children.
In sum, reducing the risks of trauma, crime, homelessness, and poverty—major determinants of poor health and mental health; improving access to integrated treatment for co-occurring disorders; and respecting as much as possible the importance of children to mothers with mental illness—are all measures that would make a very big difference in the hard lives of women with serious and persistent mental illness. Let’s get them on our society’s agenda for action.
Michael B. Friedman is Adjunct Associate Professor at Columbia University’s schools of social work and public health. He can be reached at mbfriedman@aol.com. His collection of writings can be found at www.michaelbfriedman.com.
