Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Mental health and parenting in rural areas: an exploration of parental experiences and current needs Gwendolyn Erin Cremers, Nicola Ann Cogan & Iseult Twamley To cite this article: Gwendolyn Erin Cremers, Nicola Ann Cogan & Iseult Twamley (2014) Mental health and parenting in rural areas: an exploration of parental experiences and current needs, Journal of Mental Health, 23:2, 99-104 To link to this article: http://dx.doi.org/10.3109/09638237.2014.889283

Published online: 03 Mar 2014.

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http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2014; 23(2): 99–104 ! 2014 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.889283

ORIGINAL ARTICLE

Mental health and parenting in rural areas: an exploration of parental experiences and current needs* Gwendolyn Erin Cremers1, Nicola Ann Cogan1, and Iseult Twamley2 Department of Education and Psychology, The University of Glasgow, Glasgow, UK and 2Mental Health Services, Cork ISA, HSE South, Ireland

Abstract

Keywords

Background: Research on parental mental health problems (MHPs) has predominantly used urban samples and focused on the risks for children. Aims: The purpose of this study was to explore rural parents’ lived experiences of parenting with a MHP. Method: Six semi-structured interviews were conducted with mothers who were using a mental health service in rural Ireland. Interpretative phenomenological analysis (IPA) was employed. Results: Themes identified were: ‘‘Being Observed and Negatively Judged by Others’’; ‘‘Overshadowed by the Duality of Parenting and MHPs’’; ‘‘Dominance of Medication Over Other Treatment Options’’; ‘‘Uncertainty (of Impact on Parenting Ability and Children)’’ and ‘‘Need for Inclusion’’. Although parents’ experienced a variety of concerns generic to parenting and mental health, living in a small, rural community was related to pronounced concerns regarding the stigma, devaluation and uncertainty associated with MHPs and service use. Conclusion: Further investigation into and consideration for the specific needs and experiences of parent service-users could benefit both parents and their families and inform service development.

Experiences, mental health, parenting, rurality, service use

Background Although parents who experience mental health problems (MHPs) can and do parent well (Parrott et al., 2008), the parenting experience may affect or be affected by MHPs (Oyserman et al., 2004). Parenting can impact upon mental health and well-being in both positive (e.g. motivation, purpose, pride) and negative (e.g. shame, guilt, inadequacy) ways (Ackerson, 2013; Everson et al., 2008). Despite adults valuing their parenting roles, they often experience considerable difficulties with parenting due to feelings of inadequacy, loneliness and a sense of being overwhelmed by the dual demands of coping with MHPs and parenting (Ackerson, 2013). Parents have also mentioned difficulties in balancing their own needs with those of their children (Diaz-Caneja & Johnson, 2004; Oyserman et al., 2000) and have requested support in structuring work, household and parenting activities (Venkataraman & Ackerson, 2008). Parents experiencing a MHP may be vulnerable and their parenting roles may not be validated or supported (Ackerson,

*This research was conducted in collaboration with The University of Glasgow, Glasgow, Scotland, U.K. and West Cork Mental Health Service, HSE South, Co. Cork, Ireland Correspondence: Gwendolyn Erin Cremers, 12 Hillside, Ballydehob, West Cork, Ireland. Tel: +353 86 160 1405. E-mail: gecremers@ gmail.com

History Received 26 March 2013 Revised 14 August 2013 Accepted 6 January 2014 Published online 24 February 2014

2003). Parents and their children report feeling judged and fearing what service-providers, family members or even strangers think about them (Cogan et al., 2005; Montgomery et al., 2006). The strain on parents to maintain ‘‘normal appearances’’ and hide their MHPs from their children adds to parental stress (Montgomery et al., 2006). The perceived stigma associated with MHPs can deter parents from disclosing their difficulties or those of their children (Cogan et al., 2004). Parents’ needs may go unacknowledged and unaddressed, and care provision may neglect to consider the service-users’ parenting in treatment and recovery options (Tunnard, 2004). Concern for the children of parents who experience MHPs has dominated the literature, perhaps at the expense of parents themselves (Ackerson, 2013). Traditionally, research has focused on the quantifiable, negative outcomes parental MHPs have on children (Newman, 2003) while neglecting parental desires to parent competently (Ackerson, 2003). Family-focused (Hinden et al., 2005), strengths-based approaches are seen as key for improving parental self-esteem and parent and child well-being (Venkataraman & Ackerson, 2008). The relationship between parenting and mental health is indirect and a variety of factors, specific to parents, children and the context in which their lives occur influences parent and child well-being (Stallard et al., 2004). Therefore, parents’ roles should be understood through careful consideration of family dynamics and the larger community context (Nicholson, 2010).

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Although qualitative research is concerned with ‘‘meaning in context’’ (Willig, 2001), few studies have explored the relationship between mental health and rurality (Thomas, 2011). Contextual differences between urban and rural populations challenge the validity of generalizing the results of urban studies. For example, the impact of MHPs is suggested to be greater in rural settings due to contextspecific setbacks such as increased stigma, inaccessibility and unavailability of resources (Smalley et al., 2010). Furthermore, due to such stigma, rural people may not be given equal opportunities to voice their experiences (Thorngren, 2003).

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Aim This study aims to explore rural parents’ lived experiences of parenting with a MHP. It is hoped that the present research will help to inform future development of service provision and to contribute to the growing body of research based in rural contexts. Lastly, this study aims to provide the opportunity for parents, who are service-users in rural areas, to have their experiences heard and valued.

Methods Research context The research was conducted in a peripheral, rural area in the South West of Ireland. Social deprivation resulting from population dispersal makes mental health service provision in this area challenging (Health Service Executive; HSE, 2010). Furthermore, in light of the current, global financial recession, recent years have seen cutbacks in service resources (HSE, 2010). Procedure A purposive sample of six, parent service-users was sought. Inclusion criteria were: (1) being a parent, (2) aged 18 years and (3) utilizing at least one mental health service in the South West of Ireland. Six face-to-face, semi-structured interviews were conducted and transcribed verbatim. Informed consent was obtained. Interviews lasted 1 h. Participants were asked about their experiences of rural life, mental health, parenting and service use and completed a brief, demographic questionnaire. To preserve participant anonymity all identifying variables were replaced with pseudonyms. All participants indicated that the summary of main findings adequately reflected their experiences. Analysis The interviews were analyzed using interpretative phenomenological analysis (IPA; Smith & Osborn, 2003). IPA acknowledges the researcher’s personal role in the interpretation and construction of themes, recognizing that data interpretation is a subjective experience (Smith & Osborn, 2003) and that alternative interpretations are possible (Willig, 2001). Analysis followed guidelines by Smith (2011). Profound, emotion-laden or significant discourse and preliminary observations and interpretations were noted. Items which shared commonalities were grouped into clusters to

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form preliminary sub-themes. This ‘‘grooming’’ process was repeated until transcripts were coded thoroughly. The preliminary sub-themes were organized into themes according to frequency and content. The researcher’s ideas, observations, perceptions and concerns were noted throughout the research process. Continuous reference to the research question and transcripts was made in order to check the fit of themes with the larger data pool and research aim (Smith, 2011). Reflexivity My own experiences of rural life in the South West of Ireland may have shaped my interpretation of what living in the area is like. As a fellow community member it is possible that participants withheld personal information for fear that confidentiality and anonymity would be breached. As a researcher who is unfamiliar to parenthood, participating mothers may have felt uncomfortable disclosing information because they sensed that I would be unable to identify with them. However, it is also possible that the mothers felt more comfortable disclosing their experiences of parenting precisely because I was removed from the parenting role. Participants Six mothers participated (M age ¼ 42.3, age range: 37–62). Four mothers indicated that they felt under ‘‘extreme financial pressure’’. Three mothers lived in towns (53000 inhabitants), two lived in the countryside (3–10 miles from a village) and one lived two miles outside of a town. Four mothers were caring for their children (M age ¼ 11.25, age range: 3–18) of whom three self-rated that they did 80–90% of the parenting. The other two mothers had adult children. One mother of adult children had previously lost custody of her children. Three families were receiving supports from child mental health services. Two mothers had been diagnosed with bipolar disorder and one with post-natal depression. Three mothers who experienced depression/anxiety were unsure whether they had ever received a diagnosis. Five mothers were supported by public, mental health services while one mother availed of private supports only.

Results Five main themes were identified. These were: ‘‘Being Observed and Negatively Judged by Others’’; ‘‘Overshadowed by the Duality of Parenting and MHPs’’; ‘‘Dominance of Medication Over Other Treatment Options’’; ‘‘Uncertainty (of Impact on Parenting Ability and Children)’’ and ‘‘Need for Inclusion’’. Being observed and negatively judged by others One concern raised by participants was the ‘‘close-knittedness’’ of their communities, resulting in fears about being observed and negatively judged by others. Mothers were concerned with their self-presentation and the impact of stigma on their families should their MHPs be exposed. Mothers mentioned narrow-mindedness, questioning-looks,

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gossiping and feeling that one’s actions were watched by individuals living in their communities; as Kate discussed:

and you’re constantly kind of thinking about him’’ [Judith].

‘‘They’re so narrow minded, it would be exactly like that, ‘oh she’s a bit not right in the head’[. . .]‘not the full shilling’’’ [Kate].

Some mothers felt that their mental health compromised their parenting and vice versa. Parenting was experienced by Helen as ‘‘glossing-over’’ underlying MHPs; being a parent was described as providing doctors with ‘‘an excuse’’ to account for symptoms of exhaustion. This led to feelings of being ‘‘patronized’’ by health professionals. One mother felt that because of her MHPs she was being treated like the child in the family.

This concern also related to their interactions with social and healthcare professionals. Denise described feelings of embarrassment when she accompanied her daughter to see a mental health practitioner at their local health centre.

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‘‘There were other people there and . . . it was very embarrassing. I was thinking ‘oh what if we see somebody we know?’ and I’m sure she [daughter] felt the same’’ [Denise]. For Denise, the discomfort and embarrassment was aggravated by an unspoken concern that her daughter was also worried about the possibility that they would meet someone they knew. Feelings of discomfort and embarrassment were in conflict with Denise’s parenting responsibilities to help her daughter seek service support. In order to maintain a positive self-image and avoid judgment by others in the community, mothers hid their struggles. ‘‘I wouldn’t let anyone think that I couldn’t cope . . . [. . .]that it’s something I can’t deal with’’ [Kate]. Nevertheless, the importance of being able to ask for help from both statutory and non-statutory services was valued. However, access to mental health supports was often complicated by other family members’ reluctance to engage with services. ‘‘If I was on my own we probably would all be having family therapy[. . .]but, because my husband would be sooo anti-anybody knowing there’s a problem, we wouldn’t . . .’’ ‘‘. . . certainly my husband would not want me to be seen as somebody that’s suffering depression’’ [Helen]

Overshadowed by the duality of parenting and MHPs Parents described their sense that the duality of living with MHPs and their parenting responsibilities were, at times, incompatible and competing entities. They referred to feeling as if their parenting role was ‘‘overshadowed’’ by their experiences of MHPs. ‘‘Just not being able to . . . fully concentrate on your family[. . .]there’s always this overshadow of . . . this problem, mental health problems., they seem to kind of, I don’t know . . . change you or . . . not let you be who you could be’’ [Kate]. ‘‘Before we had Timmy [son] . . . .I used be too, ‘am I going up am I going down?’ You’d be constantly thinking of yourself. Whereas with Timmy, I think ‘have I enough nappies?’ and ‘what’ll I get for the dinner that he’ll eat?’

‘‘I feel like sometimes I’m the naughty girl ‘go and have a rest’ because I’ve said such a thing to Lilly [daughter] or I’ve pissed him [husband] off.’’ [Maria]. For some mothers, the experience of MHPs made it difficult to focus on their families and realize their parenting potential. Feelings of tiredness and overwhelm competed with mothers’ parenting roles for energy and resources; further perpetuating feelings of guilt and inadequacy. ‘‘On a bad day for me I find it . . . [. . .]hard to cope. [crying] And I find it hard to do basic, everyday things that I feel I should be able to do as a mother’’ [Helen]. Dominance of medication over other treatment options Mothers emphasized how medication dominated treatment options. All mothers who were taking medication (n ¼ 4), reported feeling misled or devalued given that this was often the only treatment option made available to them. ‘‘I just feel the doctors just want to throw antidepressants at me [sobs]’’ [Helen]. ‘‘I don’t feel I’ve got any support. I feel like I’m constantly banging my head on the wall with doctors and chemists over medication’’ [Maria]. These feelings stemmed from unmet expectations of what medication could achieve and from unexpected side effects such as withdrawal, drowsiness and decreased sexual desire. Mothers felt disillusioned that medication appeared to be the dominant treatment option available to them in coping with their difficulties. It was clear to some mothers that a variety of lifestyle factors, including number of children, contributed to their experience of living with MHPs and consequently impacted on their parenting ability. ‘‘I don’t think I’ve ever met a psychiatrist who said ‘what time approximately do you go to bed? Do you sleep well? Do you have any bit of exercise during the week?’’’ [Judith]. Judith expressed confusion and frustration regarding the narrow focus she considered psychiatrists had on ‘‘symptoms’’ of MHPs and the perceived lack of support and understanding for patients as parents. However, mothers

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availing of counseling and/or therapy felt that this had provided a non-judgemental, ‘‘safe’’ place where concerns regarding their children could be discussed. Uncertainty (of impact on parenting ability and children) Participants described feeling ill-informed and unclear about the impact of their MHPs on their parenting and their children. As primary care-givers, mothers were worried about the quality of their parenting and uncertain about how to talk with their children about MHPs.

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‘‘I was afraid to make another mistake. I felt I had caused so much . . . . I was afraid actually of what to do’’ [Denise]. Two mothers were uncertain about having access to their children due to their MHPs. Judith described the difficulties she had in getting an adoption approved while Hilda explained how her MHPs resulted in losing custody of her children. Hilda experienced great concern regarding the effects her MHPs might have had on her now grown children. ‘‘I suppose . . . they have each other like. I dunno sure, when they don’t talk about it we don’t know’’ ‘‘Sure they have to be kind of affected don’t they?’’ [Hilda]. All mothers experienced a sense of ‘‘self-blame’’ and fear of the potential impacts their MHPs might have on their children’s well-being. For example, Helen experienced uncertainty about her choices as a parent, particularly during more severe depressive episodes, which led to selfblame and guilt for her daughter’s experience of depression. ‘‘I don’t know, maybe I’m too soft, maybe I’ll learn in years to come that I did it all wrong, that my attitude with her was all wrong, that I didn’t bring her up right and that’s why she is the way she is’’ [Helen].

Need for inclusion Despite their experiences of being observed participants felt the desire to be valued and heard. Participants emphasized that ‘‘we all have mental health’’ and that it is ‘‘not just us’’ but a common experience shared by everyone. ‘‘We are all out there affected.[. . .]it is all of us, mental health is something that is there! Mental health exists within each and every one of us!’’ [Denise]. Denise had experienced overwhelming fear and distrust surrounding her experiences of mental health services. For Denise, it was important that the perceived power divide between service-users and providers ‘‘be broken down’’ to a realization that we all have shared experiences rather than there be clear divisions. Helen emphasized the importance of being treated as an equal.

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‘‘I think supports where you are still treated as an equal. So you are not going into a situation where you do feel lower than the person talking to you, where you feel like you’re doing something wrong’’ [Helen]. Mothers emphasized the desire to be able to be open about their MHPs within the family and community. Being able to be open about one’s MHPs was seen as key to well-being and recovery. ‘‘I just wish people weren’t so afraid to say ‘oh, yea I suffer from depression’ or, ‘I’m struggling’ or ‘I’m finding it hard to cope’’’ [Helen]. Two mothers expressed a desire to reciprocate and help others. Helping others in similar situations was envisioned as empowering and seen as an opportunity to make use of one’s experiences of MHPs and parenting.

Discussion Overview This study focused on the experiences of parents living with MHPs in rural areas. The findings indicate that living in a rural area may enhance the perceived stigma associated with MHPs. Participants felt that although their parenthood made a difference to their mental health this was generally unrecognized by services. Medication was perceived as the dominant treatment option leaving mothers feeling disillusioned and unsupported. Mothers reported that feeling uncertain about the impact their MHPs had on their parenting caused undue distress. Mothers emphasized a desire to be able to open up about their MHPs and to be treated as equal. Rurality Unique to the present study was mothers’ enhanced sense of being watched and scrutinized in their rural communities. The perceived decreased privacy and increased stigma is in line with previous research suggesting that the impact of MHPs in rural areas is pronounced by a lack of anonymity (Smalley et al., 2010). Decreased privacy led to fears about how one’s self and one’s family were viewed by others in their community. As found in previous research (Ackerson, 2013; Cogan et al., 2005), parental avoidance of discussing MHPs within their families may have been influenced by an underlying concern regarding stigma within the family. Having the opportunity to help others was identified as being beneficial to some mothers. The desire for reciprocity may reflect empowerment and the re-establishment of self into the social community. Among rural inhabitants reciprocity is emphasized as a way to engage with the social community thereby enhancing well-being (Thorngren, 2003). Parenting Similar to previous research (Ackerson, 2013; Diaz-Caneja & Johnson, 2004), participants stressed their responsibility to protect and nurture their children. However, this responsibility was complicated by the perceived challenge of living

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DOI: 10.3109/09638237.2014.889283

with MHPs, distrust for service supports and the related stigma. As reported by Everson et al. (2008), mothers in this study described feeling that their MHPs compromised their parenting potential. It was clear from mothers’ accounts that feelings of inadequacy caused frustration and distress. However, the present research also suggests that parenting may also impact on mental health in terms of having difficulty accessing appropriate supports in a rural community.

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Service use Previous studies have found that parents feel dissatisfied with service provision (Bassett et al., 1999) relating to parenting supports in particular (Diaz-Caneja & Johnson, 2004). Participants indicated that counselling and/or therapy was helpful for them as parents because it provided them with the opportunity to discuss their parenting concerns. However, there was a general dissatisfaction with the perceived dominance of medication in treatment options. These findings capture both the sensitive nature of, and need for a more holistic approach to supporting parents experiencing MHPs (Tunnard, 2004). Lastly, breaking down the divide between service-users and providers was viewed as being essential to mental health service improvement. As a consequence of peoples’ need to feel useful and empowered, treating service-users as equal participants in their recovery may help to promote service provision in rural areas (Thorngren, 2003). Perhaps in response to the many challenges parents were faced with, the need for inclusion within the community, family and mental health services was emphasized. In accordance with previous research (Bassett et al., 1999), participating mothers indicated the need to be perceived in a realistic and not a stereotypical light. Empowerment, being heard and listened to were all seen as ways to validate themselves as parents and to enhance well-being. Limitations and recommendations A word of caution regarding the use of a convenience sample is necessary to highlight that these findings are not necessarily reflective of all mothers, living in rural areas, who experience MHPs. Six mothers is a relatively small sample size. It is possible that different themes would have emerged if more mothers had participated. Nevertheless, strong commonalities between mothers’ accounts emerged and previous guidelines suggest that six participants is an acceptable and recommended sample size for research using IPA (Smith, 2004, 2011). Participants with MHPs who have had positive experiences with parenting and service use may be more likely to participate in research (Everson et al., 2008). While participants in this study discussed some positive experiences with local services, negative experiences were also discussed, with two participants describing primarily negative experiences. In order to provide a deeper, multifaceted understanding of parental MHPs, future research should strive to include the perspectives of others (e.g. co-parents/partners, children, practitioners) in rural communities.

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Given that rural communities are numerous and diverse (Thorngren, 2003), further research using rural samples is needed in order to gain greater insight into the diverse range of experiences which are prevalent among such populations.

Service implications and conclusion Mothers concerns about parenting and their desires to be open about MHPs suggest that service-providers should talk with parents about their experiences of parenting and mental health. Mothers expressed concerns about the effects their MHPs had on their children suggesting that family interventions may be helpful (Hinden et al., 2005). It is suggested that clear and consistent guidelines on how to identify, assess and support parent, service-users and their families be provided (Ackerson, 2013). Positive experiences with the mental health services may encourage parents to seek supports for their children when necessary (Nicholson, 2010). In relation to mothers’ desires to belong, meeting the need for inclusion in the community and health-care may help to decrease mothers’ sense of devaluation, secrecy and uncertainty. As family members’ reluctance to seek supports impacted upon mothers’ own willingness to seek supports, it would seem beneficial to focus on reducing stigma within families. Through offering family sessions, service-providers can help improve family communication and work to reduce stigma within the family (Campbell, 2004). Some mothers commented on the dominance of medication over other treatments which left them feeling disempowered. The dominance of medication may inadvertently minimize or undermine other important aspects of healthcare and well-being (e.g. talk-therapy, diet, lifestyle; Ramon, 2009). Therefore, sensitivity to parents’ socio-emotional needs is advised. Adopting a recovery-focused approach could empower parents experiencing MHPs to improve their everyday lifestyles (Ramon, 2009). In conclusion, recovery-focused care requires investigation into and consideration of the specific needs of parents. Service-users may need support in the parenting role. This could take the form of: (1) guidance on how to discuss mental health problems with their children, (2) support with improving family communication and (3) the provision of more detailed information regarding treatment options. Importantly, service-providers need to be provided with clear guidelines and/or training about how to support service-users in their parenting role. Future research and service provision can help to empower parent, service-users by requesting and valuing their efforts, opinions and ideas for service development.

Declaration of interest There are no conflicts of interest to declare.

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Mental health and parenting in rural areas: an exploration of parental experiences and current needs.

Research on parental mental health problems (MHPs) has predominantly used urban samples and focused on the risks for children...
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