DEE WILSON CONSULTING

(Originally published March 2012)

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Depression has an important causal influence on both rates of physical abuse and neglect by increasing parents’ irritability with children, while reducing emotional responsiveness and, in extreme cases, virtually immobilizing parents. Severely depressed caregivers often have difficulty supervising young children or providing basic care and nurturance on a consistent basis. Furthermore, some depressed persons are highly irritable with quick tempers that increase the risk of harsh reactions to normal child behavior.

 

The widespread personal experience with mild depressive symptoms may lead to overconfidence that depression is well understood, but this is not the case, at least for severe forms of this debilitating condition. Severe depression is not a homogenous phenomenon. Monroe and Hadjiyannakis (2002) assert that “different people diagnosed with major depression often display considerably different permutations of the requisite clinical features.”  Nevertheless, common depressive symptoms include loss of energy, lack of interest in the surrounding world, sadness, sleep disturbances, poor appetite,   reduced ability to experience pleasure, emotional misery, apathy in the face of threat, hopeless/ helpless attitudes regarding the future and negative self-appraisal. These symptoms include both affective and cognitive elements. Some symptoms (hopeless / helpless attitudes regarding the possibility of effectively coping with challenging conditions) are potent combinations of feelings and beliefs that can be difficult to change.

 

Risk factors for depression include poverty, trauma, alcoholism and other forms of substance abuse, female gender, low rank in pecking orders and the combination of old age and poor health. The common themes suggested by this list are an enhanced expectation of painful experiences and a visceral sense of powerlessness. Andrew Soloman ( 2001) asserts that low income depressed adults often feel “so helpless that they neither seek or embrace support.” Regarding elevated rates of depression among women, Soloman comments “since the high rates of women’s depression do not reflect a genetic predisposition that we can currently locate, we can say with some assurance that the rates … could be reduced in a more equitable society.”  Among parents with open child welfare cases, depression is often part of a co–occurring disorder, for example, PTSD, substance abuse and depression, a combination that research on co–occurring disorders (Sallman and Newmann, 2004) has found often follows early histories of trauma and experiences of intimate partner violence.

 

This discussion suggests a theoretical perspective: depression is a common response to repeated experiences of powerlessness.  In its extreme forms, depression includes deep seated beliefs regarding one’s ability to take effective action in response to challenges, and in some social environments may be viewed as a normal reaction to stigma, pervasive racial/ ethnic bias or overwhelming threat, hardly deserving a mental health diagnosis. Nevertheless, when depressed parents are unable to care for themselves or their children, and are unwilling or unable to take simple steps on their own behalf, or accept genuine offers of help from family, friends or professionals, they begin to elicit strongly moralistic reactions and community intolerance of parenting deficiencies and/or extreme conditions in the home that sometimes defy belief.

 

Albert Bandura (1997) maintains that “The things about which people get depressed take varied forms, but a profound sense of personal inefficacy to bring about positive outcomes that give satisfaction to one’s life is the central common factor in the different sub – processes of depression.” Bandura’s perspective is that self- efficacy depends on a set of beliefs regarding the ability to take potentially effective action; and these beliefs concern both control of internal mental states and the ability to influence the external environment.  Confidence in one’s ability to regulate emotional states, thoughts and actions is critical to a person’s belief that he/she can affect environmental conditions. This is as true of school age children as it is of adults.

 

S.J. Rachman’s study of fear in combat (1990) emphasizes the importance of a sense of control and of confidence in managing rational fears. Rachman writes, “Fear seems to feed on a sense of uncontrollability, yet arises and persists when a person finds himself in a threatening situation over which he feels he has little or no control.” Rachman describes how anxiety reactions among airmen in World War II were often followed by depression: “The most common pattern was for air–crew members to show a gradual accumulation of symptoms, such as insomnia, loss of appetite, tremor, extreme startle reaction, irritability and tension.” The airmen became aware of declining control over their reactions. He writes, “Muscle coordination was replaced by uncontrollable tremors, jerky movements and tension…their ability to sleep was impaired and they started to experience nightmares. Various gastric symptoms such as nausea, vomiting and diarrhea appeared. They also reported a loss of appetite and various pains and aches, with headaches and backaches being particularly common.”

Rachman asserts that “the fliers diminishing control over their own reactions and the dangers to which they were exposed resulted in deficits in motivation, emotion and cognition… Cognitively, they suffered a growing pessimism about their chance of surviving. Some airmen became depressed and secluded themselves from their friends. Their thinking and behavior deteriorated (my underline).”

 

Readers familiar with trauma research will recognize PTSD symptoms in Rachman’s description of airman demoralized by the uncontrollability of their situation. In addition, in Rachman’s account, depression follows anxiety and trauma symptoms rather than vice versa. Depression can be the result as well as the cause of diminished self-efficacy. Furthermore, objective dangers and rational fears combined with gradual loss of control over bodily reactions in the pathway to the airmen’s depression, then led to social isolation and loss of motivation. Severe depression often has rational elements and can include plausible beliefs about the social environment; but nevertheless may ultimately lead to an inability to care for oneself or others, much less meet tough challenges.

 

Robert Sapolsky (1998) offers an account of depression based on Martin Seligman’s experiments in which animals subjected to uncontrollable and unpredictable electric shocks will often not even attempt coping responses in a new situation, a phenomenon Seligman describes as “learned helplessness”. Sapolsky believes that major depression can result from severe lessons in uncontrollability for those persons who are already vulnerable by virtue of genetics or past experiences, for example trauma histories. Sapolsky quotes Seligman, “according to our model, depression is not a generalized pessimism but pessimism specific to the effects of one’s own skilled actions.” In effect, severe depression is an energetic and cognitive shutting down of the organism as a response to anticipated painful experiences with which the depressed person believes she (or he) cannot cope.

 

Dynamics in Chronic Neglect and Chronic Maltreatment

 

Chronically relapsing conditions such as substance abuse, depression and PTSD lead to two main dynamics in chronically neglecting and chronically maltreating (i.e., neglect plus physical abuse and/

sexual abuse) families: (a) loss of self-efficacy and (b) collapse of social norms around parenting. The divergence from community norms can be mild or extreme to a remarkable degree. Leaving a sleeping baby in a crib for a few minutes while a parent runs to a grocery store for a food item or two is mildly divergent from the expectation that young children will be supervised at all times; however, leaving a toddler in a playpen for days at a time (as happened in Washington State a few years ago) while the mother lived elsewhere with her boyfriend was a collapse of parenting standards. Erratic or inconsistent supervision of ambulatory pre-school children creates risk of accidents; but locking pre-school children in bedrooms for hours at a time or days is another order of parenting deficiency.

 

Loss of self-efficacy takes a variety of forms: the inability to cope with the basic needs and attention getting behavior of children;  an apparent indifference to the hygienic condition of homes; feeling stuck in violent or emotionally punishing relationships; the passive resistance to offers of help or unwillingness to seek help; the resistance to entering treatment programs; apathy in the face of threat; the seeming lack of concern with physical appearance and health; loss of hope in a better future. Several factors contribute to the demoralization implicit in these behaviors and attitudes: (1) lack of energy such that even simple tasks like cooking, washing dishes, taking out the garbage or changing a baby’s diaper seem overwhelming; (2) lack of confidence in one’s skills and capacity to meet tough challenges; (3) beliefs (which may not be articulated) that authorities will not provide help or keep promises, e.g., the promise to reunite a parent with her children if she successfully completes drug treatment; (4) the belief that chronically relapsing conditions such as depression and drug/ alcohol abuse will ultimately prove too powerful to overcome; (5) the belief that the social environment is hostile and unjust, and that there is no legal or practical way to better one’s condition. The beliefs listed above regarding legal authorities and/or the social environment, absent chronic mental health conditions and substance abuse, might well lead to anger and the willingness to fight back; but demoralized persons have lost confidence in their ability to make positive changes in their personal lives, much less the capacity to join with others to fight unjust and oppressive social conditions.

 

Restoring Self Efficacy

 

Child welfare practitioners and other professionals attempt to help discouraged demoralized parents, effective engagement strategies are crucially important. Demoralized persons are likely to be resistant to offers of assistance because (a) they anticipate aversive consequences, e.g., crushing of hope and (b) they lack belief in their ability to learn or carry out necessary actions. Effective engagement strategies instill hope, neutralize fear of failure, disappointment or punishment, and reward small steps toward a renewed ability to cope. In addition, whenever possible, practitioners should offer choices rather than depending on coercion. Requiring a neglectful parent to clean their house as an initial intervention may sometimes eliminate child safety threats; but is also likely to be experienced by parents as a form of CPS bullying. The long term result is not likely to be cleaner more hygienic home environments.

 

Helping parents to meet poverty related needs is often an effective engagement strategy as well the humane thing to do, but giving a family much needed basic assistance is not a substitute for mobilizing parents to take action on behalf of their children. Similarly, solution based practice models that take their strategies from brief therapies often seek to instill hope through imagination, for example, “If you woke up tomorrow and everything was changed for the better, how would that look?” Hope based on imagining a better future is like a shot of adrenaline – it may wake a person up, but it’s not a substitute for taking action and making small practical improvements in one’s life.

 

In my personal experience, unexpected acts of kindness and positive recognition can have an extraordinary influence in cheering people up and causing a reassessment of other human beings. There is no good substitute for parental action when helping demoralized parents, but self- defeating beliefs / attitudes must also change. Cognitive behavioral therapies seek to change the beliefs and attitudes of persons suffering from a variety of maladies, as well as altering their behavior; and a number of therapies for depression target dysfunctional self- talk as a means of reducing negative self- appraisal, freeing up energy and allowing a fresh look at possibilities.

 

Child welfare practitioners should expect resistance from parents to entering substance abuse or mental health treatment programs; it is not enough to present parents with court orders mandating treatment and a few phone numbers of agencies to call for help. This is not skilled practice unless a caseworker wants parents to fail to enter court ordered treatment. Research studies have consistently found that at least half of parents mandated to complete a substance abuse treatment program do not enter and complete treatment; and some research studies (Greene, et al, 1996) indicate that 40-60% of low income persons seeking mental health treatment in publicly funded settings do not return for a second visit. One promising approach designed to address some of the practical, psychological and cultural barriers to treatment is the pre- treatment engagement session developed by Grote and a few of her colleagues (2007). The engagement session, delivered before treatment begins, is based on principles from ethnographic and motivational interviewing and encourages an empathetic exploration of reasons a parent might not want to pursue treatment. The engagement session also offers an opportunity to explore practical barriers to treatment, to interpret depressive symptoms in ways that are non-threatening and psychologically acceptable treatment and to identify personal and cultural strengths.

 

Once parents enter treatment programs, they need regular feedback on their progress, ongoing emotional support and assistance in overcoming practical barriers to treatment. Child welfare agencies around the country have begun to connect parents with peer mentors, professional recovery coaches or advocates to support the recovery process. Utilization of family treatment drug courts that give parents weekly feedback on their progress is also a promising practice for increasing reunification rates. 

 

As important as it usually is for troubled parents to enter and complete substance abuse and or mental health treatment programs, the goal of child welfare case plans should be that parents pro-actively take steps on behalf of their children’s safety and well-being. Sobriety or recovery from mental health conditions is a means to this end. Some parents with co–occurring substance abuse and mental health disorders become clean and sober but their parenting does not improve; this is especially true for parents using drugs or alcohol to medicate depression. A clean and sober parent may be a more depressed parent; or conversely, parents may not have stopped occasional use of drugs or alcohol or completed a treatment program, but have nevertheless begun to consistently engage in harm reducing behaviors. What child welfare practitioners, judges, treatment professionals and CASAs should be looking for is evidence of consistent parental initiative on behalf of children’s safety and well-being. Compliance with court orders is not a good proxy for evidence that parents’ motivation and skills are sufficient to protect children. Decision makers in child welfare agencies and courts should be able to point to specific parental behaviors that indicate their capacity to recognize their children’s needs and take persistent and effective action to meet them. 

 

References

 

Bandura, Albert, Self Efficacy: The Exercise of Control, W.H. Freeman and Company, 1997. 

 

Grote, Nancy,  Zuckoff, Allan, Swartz, Holly, Bledsoe, Sarah,  Geibel, Sharon,

“Engaging Women Who Are Depressed and Economically Disadvantaged in Mental Health Treatment,” Social Work, Vol. 52, Issue 4, 2007.

 

Herman, Judith, Trauma and Recovery , Basic Books, 1992, 1997.

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Monroe, Scott, Hadjiyannakis, Katholiki, “The Social Environment and Depression,” Chapter 13 in Handbook of Depression , edited by Ian Gotlib and Constance Hammen, The Guilford Press, 2002.

 

Newmann, J., and Sallmann, Y., “Women, Trauma Histories and Co-Occurring Disorders: Assessing the scope of the problem,” Social Services Review, September 2004.

 

Rachman, S.J., Fear and Courage, second edition , W.H. Freeman and Company, 1990.

 

Sapolsky, Robert, Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress – Related Diseases and Coping , W.H. Freeman and Company, 1998.

 

Seligman, Martin, Helplessness: On Depression, Development and Death , W.H. Freeman and Company, 1975.

 

Soloman, Andrew, The Noonday Demon , Simon and Schuster, 2001.

 

Turnell, Andrew and Edwards, Steve, Signs of Safety ,  W.W. Norton, 1999.

  

deewilson13@aol.com

    

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