Mental illness and a ‘good enough mother’

Seema was found by the police near the Bengaluru railway station, clutching her small infant, dishevelled, confused, and scared. Seema could not remember her name and spoke a dialect of Bengali and Assamese which we did not understand. The infant had to be placed under protection by the Child Welfare Committee till her mental illness was treated and she would be able to look after him. It took three months of medication and rehabilitation for us to be able to have a coherent conversation with her.

Yet, through it all, the one thing she remembered and talked about was her little baby. It was nearly five months before she was well enough to be reunited with little Ankur, an adorable little infant who was the darling of all at the Shishu Vihar. Should she give up the baby for adoption? How would she take care of the baby? She had no address, no money, and no identification. What was our responsibility to the infant and to the mother?

These were some ethical questions that our team grappled with. The joy when she was reunited with her infant was palpable. Seema was all smiles, she did not need language to convey her emotions and the infant cradled comfortably in her arms, resumed feeding at her breast as if the three months of separation did not matter at all. There was not a single dry eye in the team that day.

There are several such stories of mothers with mental illness and their young children and the value of reunification. The recent incident of a woman with mental illness whose child was taken away and put into foster care when she was symptomatic, without considering her choices or rights, is an example of what happens when contexts are not considered when the agency is denied, and when the system finds a short cut for child care.

Often a mother is asked by the court to provide evidence about her parenting competence. This is a hard question to answer for any mother – with or without mental illness. It is important for mental health and childcare services to work together in identifying skill deficits and providing training before a mother is asked to prove her parenting competency.

The only issue which should be considered for the cessation of parental rights (temporary or permanent) is the child’s safety. Even then, the infant or child must be kept safe till the mother becomes capable of managing the baby. Unfortunately, many other aspects seem to influence decision-making regarding parental rights, and not just mental illness including the fact that women with mental illness are more often separated or single, have poor housing, low income and may lack family support.

Informed choice

There have been many mother-infant dyads like Seema and Ankur who have been helped at the specialised `Mother-Baby’ unit at Nimhans, Bengaluru. Of the 277 mothers admitted in the service in the last four years, only one mother wanted to give up her baby for adoption, and that too after a lot of support and discussions by the mental health and child welfare teams, helping her to make an informed choice. Using systematic assessments and interventions for maternal sensitivity and skills training, mothers with mental illness are helped in understanding the infant’s cues and responses are gradually shaped by modelling and suggestions.

The majority of mothers with mental illness, though initially disturbed and possibly even aggressive towards their infants, respond to treatment and become caring mothers. Globally, there is a movement to preserve families and to focus on alternatives to parent-child separation. Organisations like the International Marce Society for perinatal psychiatry and the Global Alliance for Maternal Mental Health act as advocates for mothers and enhance research and services in this neglected area.

In India, the Mental Health Care Act, 2017 requires that mothers and children below three years not be separated in inpatient and rehabilitation facilities unless the mother poses a risk to the child. In 2011, I was a member of an expert group convened by the World Psychiatric Association which developed guidance on the protection and promotion of mental health in children of persons with severe mental disorders and emphasised the need for parenting support.

The impact of separation on mothers’ mental health can be enormous and most mothers with mental health conditions are unable to cope with the trauma of having a child taken into care against their wishes. While good quality mental health care is important, it is not sufficient. It has been shown that the denser a woman’s social networks, the less likely that her child will be taken into care.

A new concept of `wrap-around services’ that involves a strengths-based philosophy of care and support in `good enough’ mothering is now recommended. An important tenet of the wrap-around approach is the role of all sectors and social services helping the mother-infant dyad and not placing the responsibility of parenting on the mother alone.

(The writer is Professor of Psychiatry and In Charge, Perinatal Psychiatry Services, NIMHANS, Bengaluru)