This Flourish Position Paper argues that parents are being overlooked in the quest to improve the mental health of children and young people. It is a lost opportunity.
Introduction
In the UK, it is increasingly recognised that there is an epidemic of mental health problems among children and young people. The government regularly announces new funding for supportive activity in schools and community projects, together with promises for more psychological support from the NHS. Yet evidence for these interventions working is inconsistent and there is much dissatisfaction with how the system works. [1],[2],[3]
Our analysis has concluded that resources need to be directed more towards working with the parent rather than towards the child in isolation. This conclusion has found broad support among those who work with the psychological needs of children and young people. It especially applies to those highly-challenged families struggling with deprivation of various sorts; those who have fallen through the gaps of statutory service provision. The logic of taking a holistic family perspective, which we will outline below, seems to be overlooked.
In this paper, we examine how this situation has come about and describe, with examples, our experiences of helping marginalised parents; and how children can be better helped by taking a more holistic approach.
A family perspective
The reasons for adopting a family perspective, and directing more attention and resources to helping parents, seem clear to us as practitioners. The child’s mental health problems will typically arise, and be sustained by, adverse experiences within the family, and are linked to parental mental health problems and the resultant compromised ability to manage the demands of everyday life. If those root causes are tackled, then the whole family can benefit. Our experience as practitioners testifies to that. In addition, the benefit is long-lasting in terms of the healthy emotional development of the child and their ability to deal with life challenges, leading to huge cost savings for the nation.[4],[5]
When a child experiences something that causes psychological distress, they will seek comfort and reassurance from their parent. However, when their parent is psychologically unable to help them, and they cannot find this elsewhere, they feel isolated and helpless, leading to an escalation of psychologically-derived problems. We might therefore think in terms of helping the parent so that they can help the child. Given that a child spends much more time with their parent(s) than with a teacher or support worker, the potential for helping or hindering that child’s psychological development is much greater. Expecting schools to compensate for family-derived issues is therefore unreasonable and problematic; as one headteacher put it: “unless we see a change in the parent, we don’t see a change in the child”.
Why parents are neglected
The reasons why government intervention seems to focus on children rather than parents are less obvious. We offer the following explanations, based on our own observations from working with disadvantaged parents and from discussions with relevant stakeholders.
Firstly, we might recognise that society has a desire to help when a child is in distress; arguably, we feel better when we believe that our government is doing something on our behalf. When the parent is seen to be struggling to support the child, that desire inclines us to support a transfer of responsibility to others – teachers, social and mental health care workers and the like. Such involvement can be helpful and even pivotal, but the fact that mental health issues are increasing suggests that it is not enough for many of the young population. [6]
Our concern is that the parents’ multiple struggles are often implicitly deemed to be due to an irreversible character trait. This can lead to a vicious cycle where parents’ needs become neglected, they become ever more marginalized and the assumption of irreversibility is thereby further embedded. Some commentators even strike a moral tone suggesting that parents are not simply “bad” in terms of their capacity to meet their children’s needs, but are also by implication morally bad. The resultant rhetoric can be cruel, stigmatising and damaging. One MP recently labelled such parents as “crap” and said “there are no excuses…I blame the parents”.[7]
If it is claimed that there is nothing else to be said about the parent – it is a feature of their character – then it would follow that there is nothing that can be done about it; therefore, their way of being is irreversible. If true, it would indeed follow that society should direct resources into helping the child, in the hope that the state can compensate for emotional disadvantages which the child experiences. However, is our belief that the irreversibility assumption is false and we will evidence that below. But for now, we continue with our analysis of societal attitudes.
The second assumption, perhaps less explicitly expressed, is the idea that some parents deserve to be helped and others do not; this is a modern extension of the Victorian idea of the deserving and the non-deserving poor. To the extent that this concept applies to mental health and deprivation, it is supported by the observation that some parents are able to engage with helping organisations (and perhaps benefit) while others do not. One manifestation of this belief is the view is that society helps those that help themselves;those that do not accept the help offered do not deserve special treatment. However, such a division – into those that can be helped and those that cannot – is not defensible in terms of any theory or evidence base. It is simply an ideology. Again, we will below provide both theory and evidence to the contrary.
Contradictions
Perhaps the above explains why children and parents are being let down. Although logic says that taking a family perspective makes sense, ideology combines with natural instincts to say that society should rescue the child and try to compensate for their disadvantage in various ways.
There is however another contradiction in play. Despite the mounting evidence that mental health problems are ultimately caused by factors in the social environment, society continues to channel resources in accordance with a medical model of mental health. This then diverts attention away from societal causes – poverty, disadvantage and policies that marginalise – and places the blame instead on the individual. This assumption is beginning to be challenged. For example, the Welsh government recently recognised that:
“Mental Health is, to a great extent, shaped by the social, economic, and physical environments in which people live. Inequalities in society are associated with a significant increased risk of mental ill health. Poverty is a key player.”[8]
Whatever view one might take, it is evident that effective policy-making is undermined when society allows these contradictions to remain unresolved. One consequence of this situation is that minimal resources are directed towards preventing children’s mental ill-health. Every year a new cohort of psychologically-compromised children enter the school system.
Judging and blaming
The problem with assigning resources to parents on the basis of whether they are deserving or not is two-fold. Firstly, there is no cogent philosophical basis for the distinction, and secondly, even if there were, it is a quite impossible task to make a fair judgement. For in a complex and bewildering social environment, where everyone’s personal story has been shaped by childhood and adult adverse experiences beyond even their understanding, we are unable to collect the data to make a fair judgement. As the philosopher Spinoza noted, and modern neuroscience shows, humans are poorly equipped to unable to understand the internal forces that lead to their own everyday decisions and behaviours,[9] let alone those of others. We might object to a particular behaviour – anger, withdrawal, rejecting help, criminality, for example – but unless someone takes the effort to enquire into their causal background, they are in no position to condemn or deny help.
We agree with philosophers, such as Villhauer,[10] who argue that someone deserves help simply by virtue of the fact that they are a human being. All humans have the potential to be harmed or overwhelmed by adversity outside of their control, and may respond in ways that seem counter-productive.
Marginalisation and non-engagement
Most endeavours aimed at helping struggling parents follow the of the so-called Inverse Care Law.[11] This observational “law” says that, contrary to intention, the very people who are most in need of a caring service are the least likely to receive it. An UK example which is close to our topic is the Sure Start scheme, which was often regarded as having been used more by families with lower levels of need.[12] Lower levels of engagement seem to be common feature of marginalised and highly-challenged parents. We are particularly concerned here with psychotherapeutic help and practical, supportive help of various kinds.
Based on our experience of working with struggling families, we propose the following reasons why this happens. Firstly, services are often developed with the assumption that all individuals see the service as a positive opportunity for help. This can be far from the case. For many marginalised individuals, their trust in services, particularly statutory services, has been eroded, and accessing any such help can feel threatening. For example, a parent in crisis may fear that any disclosure of their struggle may lead to their child being taken away from them. Trust may have also been eroded by previous experiences of services where the parent has felt let down, having endured shame and even flashbacks from childhood trauma, without any benefit. Too often, the pressure of working to limited sessions rarely allows for a safe, meaningful and therapeutic exploration of adverse childhood experiences and adult adversity. A one-size-fits all service rarely meets the needs of those who have experienced long term complexity and instability.
Secondly, if an individual does engage, the type of support offered can create barriers to engagement or disappointment. For example, having to attend a group experience can be daunting and overwhelming, often fuelled by a fear of being exposed and judged by others. Parenting classes, anger management classes and the like, though helpful to some, are too generic to take into account the individual’s unique history of trauma and adversity – leading to lack of benefit and, often, a clutch of troublesome feelings, such as shame.
Thirdly, the way services are configured can create barriers. They are frequently unintegrated; and failure to attend one service may then put the client on a long waiting list for another service. This can be experienced as punitive, tending to reinforce the barriers around engagement. A further challenge is the practicalities of simply attending a meeting outside of the local community where transport and childcare can be difficult to organise. This is particularly the case for those parents who are isolated with poor support networks. It is common for parents who fail to engage with services, or give up attendance, to feel stigmatised.
There is a need to question the suitability of a one-size-fits-all generic service for complex, struggling families. As Tolstoy noted: all happy families are alike, but unhappy families are unhappy in their own particular way.[13] This chimes with our observation that the most challenged families are the most complex and deviate the most from the average. It follows then that generic service provision will become less and less helpful as the complexity and deviation from the average increases.
Taking this perspective, it is easy to see how the most challenged of parents find it difficult to engage and why the Inverse Care Law applies. It is surely unjust to develop social policy on the assumption that their lack of engagement is due to an irreversible character trait, and that therefore they are undeserving. It follows also that this injustice is also borne by the children who, by virtue of ill-conceived policy and societal condemnation, continue to suffer from the lack of a nurturing family environment.
A different approach
In various settings, the authors have had experience of developing a different approach, based on accepting the parent for who they are and the reality that their parenting has been shaped by adversity outside of their control. We have found that with a flexible, person-centred approach[14] (that avoids the engagement impediments discussed above), so-called “beyond-help” parents can be readily helped towards a greater capacity to cope and function well (in what may continue to be a challenging environment). There are three main patterns that emerge:
- The parent is simply overwhelmed by multiple challenges and unable to think straight and function in the world. After a small number of counselling sessions, the parent is able to think through and structure their challenges and how they are going to solve them. It often turns out that such parents do not have any major underlying psychological problems, although they may continue to benefit from counselling.
- The parent is overwhelmed, but also has ACE-related challenges to functioning, such as low self-esteem, difficulties in self-expression, a tendency to simplify the world, etc. More counselling (perhaps 5-15 sessions) may be needed, with some advice and advocacy support on how to engage with others to meet their practical needs. Such parents soon achieve self-empowerment and no longer need hands-on advocacy.
- The parent has complex needs both psychological and practical. Significant advocacy and problem-solving is needed to resolve practical issues, alongside counselling to deal with childhood adverse events, parenting issues and the move towards greater self-sufficiency. This work may be more long-term.
Two case histories and client statements
Maggie and her two children were living in temporary accommodation following her domestic abuse. Maggie’s anxiety had escalated and she had found it difficult to leave the building, other than to take the children to school (which was often fraught and resulted in late attendance). She also suffered from a health condition and was undergoing further tests.
Maggie was referred to the service. On initial contact, she was highly anxious about accessing support because of her limited capacity to travel to venues. As a result, a room was secured near her accommodation and Maggie was able to meet with the team in person. As a consequence of Maggie’s and her children’s circumstances, there was already some professional support in place. Maggie’s heightened anxiety prevented her from ‘keeping track of where things were up to and who was talking to who.’ The advocate was able to liaise with the professionals and update Maggie on how things were progressing. The advocate also supported Maggie in completing an application for additional financial support, which was successful.
Maggie accessed therapy and spoke in depth about her past experience of domestic abuse and current fears for her family. As a result, although Maggie still struggles with her health and her situation, she has greater self-confidence and greater ability to engage with helpers.
“It’s really good having you both working together. There’s lots of people working with me but sometimes it’s like no one’s talking to each other. This service has been very helpful especially because I can’t travel anywhere…well…because of my condition. The advocate has helped me so much. She sorted my applications and made it all work. Also, having someone of my own to talk to has really helped me especially with everything that’s happened. Talking helps me make sense of things and makes me feel better in myself.”
Isla was mum to two children, Robbie and Ashley. Ashley had additional and complex needs and Robbie was awaiting assessment for ADHD. Isla had a history of depression, anxiety as well as physical ill health at times. She had previously accessed therapy after Robbie’s birth but had been on the waiting list for six months before her sessions began. The therapy was time limited and Isla felt let down by the level of support. When Isla was referred to Flourish, she had her first meeting with the team within two weeks. She initially engaged with the therapist and then opted to access the support of the advocate alongside her therapy.
Isla used the therapy to explore past childhood abuse, eating disorder and complex bereavement. She was able to make sense of her depression and anxiety and how her well being impacted on the well being of her children as well as her beliefs about her future. Isla was able to speak to the advocate about her lack of confidence in challenging systems of support for her children. The advocate helped Isla work through her concerns about delays in her child’s EHCP assessment and contact the correct professionals to address this.
Isla is now engaging with life. She has enrolled on a Level Two health care training course and plans to enrol on GCSE courses later this year.
“This experience has helped me heal from my past. I’m gaining in self-confidence. I could not have challenged things on my own…my child being let down was so raw. The advocate made it all work. I understand my family in a different, calmer way. I’m more confident talking things through with my children and learning different ways of dealing with behaviour. I’m putting in boundaries without feeling guilty. Working with you has changed my life.”
Conclusions
We have not discussed here the rationale for helping the child and not the parent; clearly there are occasions when it is appropriate to do that. However, we conclude that in most cases where it is clear that the parent (and the family as a whole) is struggling, it is essential and more cost-effective for helping resources, both psychological and practical, be more directed towards the parent.
In our experience, such help has to avoid the various problems which we have discussed above that lead to low engagement. The provision needs to be flexible, non-judging, empathic and person-centred. The cost of such provision will typically be higher, but the benefits for all family members can be enormous.
To continue to base policy and attitudes on the basis that some parents are beyond help is both unjustified and unjust. Struggling parents just need to be better understood and helped according to where they are, rather than where providers feel they should be.
Della Austin
Andrew Garman
22nd January 2024
[1] https://www.youngminds.org.uk/about-us/media-centre/press-releases/monthly-referrals-to-camhs-reach-record-high/
[2] https://www.rcpch.ac.uk/news-events/news/record-high-over-400000-children-waiting-treatment-amidst-child-health-crisis
[3] The Good Childhood Report, Children’s Society: https://www.childrenssociety.org.uk/good-childhood
[4] https://phwwhocc.co.uk/wp-content/uploads/2020/08/Financial-burden-of-ACEs.pdf
[5] https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0895-4
[6] https://www.childrenscommissioner.gov.uk/resource/the-state-of-childrens-mental-health-services/
[7] https://www.theguardian.com/politics/2023/dec/29/tory-mp-james-daly-struggling-children-bury-north-crap-parents#:~:text=A%20Conservative%20MP%20has%20claimed,in%20giving%20children%20%E2%80%9Cstability%E2%80%9D.
[8] https://senedd.wales/media/1uchw5w1/cr-ld15568-e.pdf
[9] For an accessible dicussion of Spinoza and neuroscience, see: Damasio,A. (2004). Looking for Spinoza. London: Vintage.
[10] Vilhauer, B. (2009). Free Will Skepticism and Personhood as a Desert Base. Canadian Journal of
Philosophy, 39(3), 489-512.
[11] This law was conceived in the context of healthcare generally; see for example: https://www.kingsfund.org.uk/publications/articles/inverse-care-law
[12] In 2009, just prior to the beginning of the demise of Sure Start as a national provision, Ofsted noted that “Engagement with the most vulnerable children and families continues to be a challenge” see: https://publications.parliament.uk/pa/cm200910/cmselect/cmchilsch/130/13009.htm, §83.
[13] The opening words of Anna Karenina.
[14] We are also exploring the integration of advocacy with counselling.