In describing family life with a person with severe and persistent mental illness, Lefley (1987a, 1987b, 1989) noted a variety of behaviors of some persons with serious mental illness that contribute to the burden borne by their family members:
• Hostile, abusive, or assaultive behaviors (even if rare)
• Mood swings, other unpredictable behavior
• Socially offensive or embarrassing behavior
• Poor motivation, apparent malingering (often due to negative symptoms)
• Apparently self-destructive actions such as poor handling of money, deteriorated personal hygiene, and neglect or damage of property.
The burden that family members must bear occasionally includes abusive and assaultive behaviors in acute phases of the illness, especially in the earlier years. While infrequent or even based on a single instance, these incidents within a family are very memorable and may be dwelled on for years to come. There are a variety of other troublesome behaviors that are particularly upsetting, including symptoms such as paranoid ideation about family members and negative symptoms that lead to poor self-care.
As if these problems were not enough, parents also worry about what will happen to their adult child "when I am gone." That is, they worry about who will provide care after their own deaths, although there are efforts to help parents with estate planning that will help care for their children, a practice begun for parents of persons with developmental disabilities. Lefley (1987a) also stated that many families experience a "dilemma of functional expectancy" (p. 114). This dilemma refers to the idea that having normal expectations for the role of a family member with mental illness sometimes leads to frustration because the person has difficulty meeting these expectations. For example, parents may attempt to promote the independence of their son or daughter, that is, expect that as an adult he or she should be able to maintain his or her own apartment. Yet, when the person fails, the parents may think it is too much to expect. At the same time, if expectations are inordinately lowered, the individual may tend to live up to these low expectations, rarely reaching a level of functioning that would be considered normal.
The situation of adult children living with parents is often very stressful regardless of the presence or absence of mental illness. Indeed, the variance in burden experienced by the parents is directly related to the degree of dependence of the adult on their parents, whether or not a psychiatric illness was present. Nevertheless, the situation is not hopeless. Today's family psychoeducation and support interventions, while they involve the family very extensively, actually succeed in promoting independence (Pharaoh et al., 2004) and reducing family burden (McFarlane et al., 2003). This evidence is discussed in more detail later in this chapter.
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