1. Background
Mental disorders are among the common problems in societies (1). According to the statistics, it is predicted that half of the population in the United States experience some forms of mental disorders in a period of their lives (2). In Europe, mental disorders are estimated to be present among 27% of the population (3). At a national level, it is reported that 20% of the Iranian society have mental disorders and almost 1% of affected people need particular healthcare services (1, 4).
Within the past years, because of deinstitutionalization, advancements in therapies, psychotherapies, and use of new drugs, the number of individuals who are able to live and reproduce in the society despite having mental disorders has increased (5, 6).
Among the families of patients with mental disorder, children are at critical situations since they face several problems which may not be efficiently noticed. These individuals are called as “hidden population” subjected to the problems (7). According to statistics, about one-third of men and two-thirds of women with mental disorder in the United States and nearly half of such patients in England are reported to have children (8). Based on a previous research conducted in Iran, 45.9% of female and 43.9% of male patients with mental disorders had children (9). Globally, it is believed that 25% of adults with mental disorders have children and are living together (10).
According to these researchers, it can be asserted that these children have higher rate of behavioral, developmental, and emotional problems. To date, among the long-term effects of parents’ illness on their children, the social and vocational problems have been mostly discussed (11). Although most of these children’s problems are reported to result from chronic effects of their parents’ illness (12), issues such as unemployment and low quality of life also influence their problems.
Despite the criticality of problems experienced by children of parent with mental illness, few researches have been conducted on perspectives, experiences, and the needs of these children. Therefore, therapists who deal with these patients should fully understand their needs in order to offer decent health care services. It is also of prime importance to notice the needs of these children to improve and enhance their normal development and growth (13). Unfortunately, there are only a limited number of plans assigned to these children (2).
Most of the studies conducted on mental health and marriage have focused mainly on the influence of marriage on mental health and the effect of mental health on the quality of relationship or divorce (14), and only little attention has been paid to the effect of parents’ mental disorder on the marriage of their children.
2. Objectives
Based on the narrow knowledge about the children of parent with mental disorder and the necessity of study in this area, this research was designed to define the challenges concerning the marriage of children of parent with mental illness in Iran.
3. Patients and Methods
This report was part of a more comprehensive study conducted using qualitative method (15). The larger study focused on the mental health needs among children of a parent with mental illness to discover how such needs originate and develop. One of the main categories that emerged in the original study was reported in this article.
3.1. Setting and Samples
Our study population was selected based on a purposeful and theoretical sampling method. Participants included 15- to 25-year-old children of patients with mental disorder who had at least a history of one course of hospitalization. The participants recruited in our study consisted of the children who were living with their parents while with no history of mental disorder. The first participant was a 17-year-old girl whose father suffered from schizophrenia. All children mentioned of facing important challenges and events in their lives such as marriage or interaction with healthy parents and therapists. Through performing theoretical sampling, healthy parents, children’s spouses, nurses, psychologists, and counselors were also involved in this study according to the data implications. The total number of 17 participants of this study were ten children of parents with mental disorder, their family members (including one healthy parents as well as the wife of a child of parent with mental illness), and professional therapists (two with MSc degree in psychiatric nursing, one with MSc in clinical psychology, and one with MSc in consulting).
3.2. Ethical Considerations
This research was conducted through obtaining permission from the Ethics Committee of Nursing and Midwifery Faculty of Iran University of Medical Sciences, Tehran, Iran. To respect the participants’ rights, a separate and private meeting with each participant was arranged prior to the actual interview. Participants were also assured to have the right to withdraw from the study at any time. Moreover, every attempt was made to ensure the privacy of participants during the interviews. Written informed consent was obtained from all participants and all data were treated as confidential.
3.3. Data Collection
After obtaining the participants’ consent forms, background information of the study population was collected. This information was purely used for the general description of the participants. Interviews were performed privately for each participant, i.e. only the participant and the interviewer. Based on agreement made with the participants, the interviews with patients’ family were conducted in hospital and the therapists were interviewed in their work places. The necessary data were gathered through semi-structured interviews lasting from 45 to 100 minutes. The average duration of interviews was 60 minutes. Data collecting process was performed within a 16-month span from October 2008 to February 2009. Interviews were conducted using digital voice recorder. Following each interview, the recorded file was transferred to a computer and the verbatim typed to preserve the data integrity and avoid researcher’s subjectivity. Interviews transcription started in less than 24 hours after each interview and memos were written by the main interviewer for each participant.
The interview guide was designed based on initial review of the literature and consisted of open-ended questions to allow the respondents to explain their own experiences. After a warm-up conversation with each participant, collection of data was initiated with open-ended and over-arching prompts: “what happened the last time your parent was hospitalized?”; “Please tell me about your parent’s illness”; “Can you explain your parent’s illness?”; “What does your parent’s illness mean to you?”; “Can you explain what happened in your parent’s most recent mental health episode?”; “Does the illness have the same phase in each episode?”; “What do you want, wish, or desire when an episode occurs?”; “Who helps you?”; and “If someone wants to help, what is your request?” Some of these same questions were used when interviewing the other participants (i.e. spouses, healthy parents, health care practitioners), whereas other questions were posed based on participants’ experiences and role. For example, “Can you explain your husband’s illness?” (Spouse); “What does your son need when his father has a mental health episode?” (Healthy parent); and “From your experience, what is the most important need of children of parents with mental illness?” and “Do you feel you can help children of parents with mental illness?” (Healthcare practitioner). Further questions following these initial ones were based on the participants’ responses and emerging themes. Once the data saturation was reached, three other interviews were conducted.
During the interviews, to understand the background conditions and describe the behavioral diversity in the children in each case, observations were used. Theoretical sampling was conducted based on responses emerged during the interviews.
3.4. Data Analysis
Analysis of each interview and coding was performed before starting the next interview, as the data emerged from the previous interviews and concepts were extracted from the previous transcripts, which defined the trend of next interviews. Data were analyzed using constant comparative analysis method.
4. Results
Participants of this research were the children of parents with mental disorder, their family members, and professional therapists. Patients’ family included six female children, one daughter-in-law, and two mothers (healthy parents). Patients’ parents included four fathers and six mothers among which five were diagnosed with mood disorder, four with schizophrenia, and one with obsessive-compulsive disorder. Patients had history of hospitalization in mental centers of three to 50 times, with an average hospitalization frequency of 12. The average age of children was 12 years (range, 17 - 26 years). The four therapist participants were working as the members of scientific board of the universities and all with a Master degree. The average work experience of the therapists was 13.75 years (range, 5 - 20 years).
4.1. Gloomy Horizon
The marriage of the children of parent with mental disorder was an important challenge they were facing. Marriage is a more challenge matter for these children. This shadiness represent in both premarriage and postmarriage.
4.2. Premarriage Issues
Many people are not willing to marry such individuals. People see these families situation in different way and change their mind to marriage. Parent with mental illness is a great barrier to children marriage. One of the healthy parents stated, “This is embarrassing when someone wants to marry my daughter, but changes his mind after finding out about our situations. I agreed with my daughter, who holds a BSc, to marry a guy having only a high school certificate, as before that whoever came for my daughter, changed his mind after a while by seeing our conditions and this created a sense of inferiority among my kids.”
This issue is important not only for girls but also for male children. One of the participants mentioned his idea over this subject as follows: “Actually this makes about 30% to 40% of our problems. So, we never think about marriage. We are afraid of marriage. Then, I have to make my partner more familiar with mom if I want to marry. This have a very good positive effect since so many people think of the other family as an important criterion. You must see whether they agree with this situation.”
In addition, talking about marriage is difficult for many children when considering their parent’s problem. One of these children describes his problem as follows: “It was very difficult for me once I wanted to talk about marriage. I was wondering whether they accept my proposal. It was a very difficult experience.”
4.3. Postmarriage Issues
Aside from the prenuptial problems, the children who succeeded in establishing a family life were still subjected to a series of problems such as challenges with their husband and his relatives provoked by their parents’ illness. One of the participants mentioned her experience as follows: “When my sister got married, her husband and his family were unaware of our problem. Once they found out about that, they started to annoy us. Her husband did not do anything bad to us but his mother was awful.”
One of these children’s wives believed that there was no chance to get permission for marriage before becoming familiar with these children and their families. She described the situation as follows: “It is a helpful factor if the marriage candidates have previous interest in each other. In this case, the individuals mutually accept their situation as they are in love. However, when an unfamiliar person wants to marry and tells that his mom has such an illness or the girl’s family starts to find out some information over the boy’s family, too many problems may arise. We knew each other before the marriage, but if we were not relative, so many problems would occur. Talking about such an illness is difficult. You have to tell your problem and then waiting for the other side to think and make decision. If my fiancé was not my relative and wanted to marry me and tried to tell me about his situation, then I had to think a lot and this also made me very depressed.”
This problem was even demonstrated in therapists’ experiences. One of them stated, “Another troublesome issue is the society’s outlook toward these people. For example, I myself do not like to choose my marriage partner from those with mentally ill parents as I think of the genetic possibility by which the genes of such illness could be inherited.”
One of the top concerns causing children’s anxiety was worrying about developing mental illness themselves and its transition to their children. These fear origins from their concern of having the same illness as their parents. One married child whose mother was diagnosed with a mental illness revealed, “We have decided to visit a counselor to talk about our future possible children. I want to ask my counselor whether my child will have problem if I get nervous; or if I become ill what would happen to my child. I’m scared of having a child suffering an illness. I myself am young already. If I reach my mom’s age, would I be still a healthy person?”
5. Discussion
From various points of view, marriage is considered among the most important events occurring in people’s lives (16). Without any doubt, marriage is a critical stage in personal and social development of everyone. Children of patients with mental disorder establish their lives based on cultural norms of the society and the beliefs they have experienced concerning mental illness. This process has an important role in development of the concept of their lives’ most vital events such as marriage. Our participants’ experiences revealed that although marriage is considered as a normal trend in our lives, it is assumed as a big challenge for children of parents with mental illness. Several studies have shown that the rate of marriage for children of parent with mental illness is less than those with healthy parents (17). Many people are not willing to marry such children. The findings of the present study revealed that the most important reason for other people to avoid marrying such persons is their fear of heredity status of their illness and the possible transfer of disorder to their own children. In connection with the occurrence of such event, some studies have shown that these disorders can be genetically transferred to children. The participants mentioned their unpleasant experiences of their parent’s illness and the fear of having the disorder passed to their children. This anxiety is so deep that some children mention that they never decide to marry; this finding was also reported in other studies. This problem was present for all participants regardless of their sex. In addition, talking about marriage is rather difficult for many of these children due to their parents’ illness. The participants predicted a gloomy perspective for their marriage considering their parents’ mental disorder, and as a result, are not willing to discuss about marriage because they do not want to share this depressing horizon with other people. On the other hand, these children are also embarrassed to talk about their parents’ illness during prenuptial marriage meetings. Moreover, the experiences of some participants revealed that choosing or being chosen as a marriage partner is very difficult for these children. Setting aside the prenuptial problems, children who succeeded to marry, still have to suffer challenges (originated from this problem) with their spouses and their families. Accepting the fact of mental disorder in some families is not easy; this gives rise to some troubles during family incidence and marital problems and leads to some family arguments or annoyance. This is an instance of a family picture, which has been frequently observed and admitted by the children of parent with mental illness in their lives or their siblings’ lives.
Fear of developing the parent’s mental illness was found to be the predominant cause of anxiety. This is of particular importance as the literature has frequently acknowledged the risk of intergenerational genetic inheritance of mental illness (18); however, the participants of the current study also expressed fear of transmitting their own negative behaviors to their children. The anxiety of living with a parent with mental illness is too great that some children explained they do not want to marry or have children out of fear of making their own child live with such anxiety. In one case, toxic inheritances (i.e., stories given to children from family members or others that can turn out to be lies or distortions) were used to determine this type of anxiety (19).
Parental mental illness poses a major problem for many children and this can seriously affect their social, physical, and emotional well-being. The findings of our study highlighted the issues surrounding the marriage of children of parent with mental disorder. These findings can be used for delivery of care to these children. If the health care providers intend to plan a holistic approach for the family of a parent with mental illness, the children must be given a specific position. In this approach, the issue of marriage and its challenges should also be considered as an important topic. Such programs provide many benefits for both the parent with mental illness and the children while reducing the cost of care services within the health care system (20). As our findings are subjective in nature, their application in other contexts should be made cautiously. For generalization purposes, similarity between contexts must be considered. Some children refused participation in the study, leading to further limitations. Although the data were saturated, a greater number of participants could increase the depth of the data.
