NASW Social Work Talks - EP 122: Something's Really Wrong Here: What Social Workers Should Know About Families with Adult Children With Mental Illness

Episode Date: October 22, 2024

Dr. Judith R. Smith, LCSW is author of the new book, Difficult: Mothering Challenging Adult Children Through Conflict and Change. We chat with her about her research and the impact of having a "difficult adult child" on aging mothers and explore how social workers can best support these parents in navigating both the emotional and practical challenges they face.

This episode of Social Work Talks is sponsored by Ironwall by Incogni. This is Social Work Talks. I'm your host, Aliyah Wright. This episode of Social Work Talks is brought to you by the NASW Virtual FAR Forum, being held October 29th through the 31st, and will focus on mental health. Joining us today is Dr. Judith R. Smith, LCSW, author of the new book, Difficult Mothering, Challenging Adult Children Through Conflict and Change. Dr. Smith is a New York City-based psychotherapist, professor, and researcher on women's issues as they age. She is a professor emerita at Fordham University, and she offers online support groups for mothers with difficult adult children. Her book is based on a three-year research project

and brings to life the stories of 50 women, each over 60 years old, whose lives were drastically altered by becoming the default safety net for their adult kids. According to research published in the journal Psychiatric Services, about 35% of older adults with serious mental illness live with family members. I am really glad to be here. Thank you for inviting me. Dr. Smith, thank you so much for joining us. Before we dive in, we'd like to ask our guests who are social workers how they got into the profession. In some ways, I always knew I was going to go into a helping profession. It was my mother's dream for me, and it was also a good fit. I went to a college where we had work periods every year, so I had the opportunity to work in a children's psychiatric

hospital, a regular hospital for children. I worked for a whole year with emotionally disturbed kids. So I knew that I would eventually become a psychologist or a psychotherapist or a social worker. So it was sort of, I knew it was my destiny and I fulfilled my destiny. I actually, when I graduated, I, for two years, went to California. I'm from New York City. and it was the time of the Vietnam War and I got involved in community organizing and making films. I made the first film about women's liberation. It was just at the women's movement was just beginning and then I went to social work school a couple of years after that. she was not she could not go to college till later in her life but she did actually she and

my father before i was even born this was like in the 1940s uh had been in psychotherapy it was a time of sort of avant-garde people believing in Freud and psychoanalysis, and they both did that, and she hoped that I would be able to provide that for people. Wow. Speaks volumes. Well, I... So tell us a little bit about your book. Actually, my first job was a psychiatric hospital but I also had an opportunity to work with Margaret Mahler who was a psychoanalyst who was the first person to directly study children healthy children and she had edited she had shot and edited films about child development that they wanted somebody to edit them and since they knew I was a filmmaker

and a social worker, I was the perfect person. So I spent three years working part-time as a social worker and part-time watching all these movies about mothers and babies. And I didn't have a child myself. And I became fascinated with seeing child development in front of my eyes over and over again, because you could wind back and see everything. But I left all that really interested in the mothers themselves. And that sort of started me on a trajectory to be interested in mothers' experiences. And for the first part of my career, when I became a social work professor after getting my doctorate, I was focusing, my research was on the first three years of life in terms of social policies that affected mothers and their young children. And I did that for many

years. And then I moved into gerontology because it was a big push in social work for social workers to pay more attention to older clients and to do research about older people. And as I did that, since I had this years and years of experience of mothers and young babies, I became curious, what is my colleagues writing about mothers and older kids? And I was actually getting older myself and my son had gotten older and all his friends had gotten older. So I was curious. I realized from a personal basis that mothering didn't end when my son was 18 or 20. And I wondered what people in gerontology were writing about how this impacted older women's lives if their kids, you know, still needed them. And I was really shocked to find out how little had been

done on this. I mean, it's really sort of a black hole. There's very little written about mothering adult children. And that became the focus of my research life, my work life. And that's why I'm here today. It's a fascinating topic because as, you know, children grow older, I don't think that most people think of their children as being people who will continue to need their parents into their adulthood, but that's the opposite. So while discussing your book, the Wall Street Journal noted that parents are always in the parent role, and they highlighted the pressures on aging parents. Difficult delves into these challenges and sheds light on the hidden abuse that can emerge within these dynamics. During an interview with the New

York Times, you said, whether the kid had a substance use issue or severe mental illness or was depressed or unemployed and not willing to look for a job, what I heard was the mothers were struggling. How do these struggles impact the broader family system and the well-being of the parents involved? Well, that's exactly what my research tried to find out. I recruited in senior centers and in retiree meetings of older people. And I asked who was a parent. And then I asked what problems their kids had when they were little, you know, when they were teens. And then I said, what about when they're 40? And that's when the room became really quiet. But eventually some people said, well, drugs, divorce. And I said, well, that's, I want to

talk to you. And I gradually created a list of people who wanted to be interviewed. And what I discovered, I didn't know what problems the women would tell me they were worried about in terms of their kids or how it affected them. It could be they were marrying outside of their faith. It could have been they weren't visiting enough. That's what my mother would have said. The problem was I didn't visit enough. But in fact, the people who made the effort to come and talk to me were people whose kids had serious mental illness or substance use disorder. So these kids, some of the moms were 80, some were 75. The kids, the kids, and, you know, quotes, were 30, 40, 50, 60 years old.

But they still had serious problems. And the mothers were still involved in their lives one way or the other and still worried about them. And as you get to be 80, 85, your question is, what happens when I'm gone? wow um so difficult describes the impact of having a difficult adult child on aging mothers from a social work perspective how can social workers best support these parents first thing is to find out more about the dynamics i mean that's one thing i hope my work will do for practitioners is to begin to understand that these mothers are being impacted. They've been

left out of the picture. Even in, I mean, years ago when I worked at a psychiatric hospital, parents, it was the social worker's job to interview the parents and work on the discharge planning. Parents now, a lot because of HIPAA and many other reasons, often are not included at all And the treatment team often doesn't even want their feedback. So I think the first thing social workers need to know is that if a person, whether they're 30, 40, or 50 years old, and really are adults, they still have a parent. And particularly if they're vulnerable adults, their parents are probably still in the picture in one way or another.

And so if you're in a setting working in a substance use facility, try to change the culture. Right now, parents are in no way welcomed into the treatment plan. You know, maybe consider having groups for parents. The more you can begin to understand that this is a two generational problem, that the problems that are in the adult child's life are also impacting the mothers. I only interviewed mothers, but I know that fathers are also affected. And if we can also help the mothers, one, we're getting more bang for our buck and we're giving more mental health treatment. But also then if the parents feel that their experience is being understood, they're going to be a better ongoing resource for their kids. Because really families are the ones who are going to be there for much longer than the treatment situation. And if what's interesting, like if you Google, um, older parents and difficult adult kids or mental illness and

parents, what you're really going to find is children of schizophrenic mothers, children of alcoholic parents, children of narcissistic mothers, that the literature that's out there is all about the problems in the mothers affecting kids. But what I have written about is that there also is that the problems in the kids affect the parents and the mothers. And this is an unrecognized mental health need, and you're going to run into some of these mothers in your work. So begin to think of this as a two-generational problem and begin to have some empathy and curiosity about the mothers. I mean, unfortunately, all of us have mothers that we're annoyed at and think they should have done a better job. But as clinicians, we sort of have

put aside our own parents and begin to realize that you know like severe mental illness by that i mean bipolar disease major depression schizophrenia are not caused by uh bad mothers we more and more evidence that this is a brain disease and genetic similarly with substance use National Institute of Health is really trying to get us to think of this as a genetic disease and a physical disease that creates the cravings and not to see it as weak character and to really shift our lens. And I think mothers for so long have been blamed for their kids' problems. And they internalize it.

single woman I talked to told me that she assumed that she was the cause of her kids' problems. So I think as social workers, read about this. You can certainly read my work. There are other people who also write about how families are impacted by mental illness and substance use disorder. Actually in England, and there's a whole Association, they call it affected family members of people with substance use disorders. And the government has started giving a lot more money to the family members. Because when somebody has a substance use disorder, everybody is affected. It's not just the person with the substance use disorder problem. So I think the main thing is to, if you're working in a nursing home,

or if you're working at a rehab center or if you're working at a regular hospital floor and you have an older woman patient and you're working on discharge planning and you say, well, you know, who lives at home with you? And she says, oh, my adult son is there. Don't say, oh, that's great. And you might think, oh, good. I don't have to really think about discharge planning. you want to ask a few more questions you know is he working um what's his mental health like is he able to take care of you so don't assume that because there's an adult child living at home that that mom is going to a situation where she's going to be cared for i think a piece of this puzzle is that if somebody stops being able to support themselves, and that's the problem. I mean, difficult mothering begins when your adult child can no longer support themselves,

when their substance use problems or their mental illness interferes with being able to work. So then how do you afford where you're going to live? Either you're homeless or you come knocking on the door of your parents and say, can I live here for a little while? And every mother I talked to said, of course, but they didn't expect that this was going to be a three or five or 10 year trajectory. And the other side is that when your adult son or daughter moves back in, if they are depressed, if they are using drugs, they're not great roommates. A lot of problems emerge. A lot of the mother who may be 60, 70, or eight years old is used to having quiet in her house. She's used to being able to bring home her meals from the senior center and assume she can

eat at night, not that somebody's going to take her dinner out of the refrigerator without telling her. She doesn't expect to be cleaning her house after her, you know, she thought she was done with taking care of another person and to be older and suddenly be back in that position and being talked to. The mothers all would use the word that my son can be very disrespectful or my daughter can be very disrespectful. She can be very aggressive. None of them said my daughter is abusive or my son is abusive. But a lot of the behaviors we would, as clinicians, label it as abuse, verbal abuse, financial abuse, particularly if you have a child with a substance use problem, they need money and they will steal whatever there is in the house. And that feels

awful as a parent to have your own child be taking your things. so dr smith um what specific interventions or resources should social workers advocate for to address these complex complex issues first you want to educate yourself about um serious mental illness and substance use disorder you know i think in most basw and msw uh programs there's only maybe one class on substance use work. Maybe if you're lucky, there's one class on working with serious mental illness. Many schools have none. So you want to find out something about that. And I think you also want to, the basic skills that you're learning in terms of forming a therapeutic relationship, being curious, all of those things are skills

that you want to bring to if you meet an older client and the places you might meet her aside in a hospital setting if you're working in a community mental health center a mother may come in because she wants help with her son her son is depressed he's not working he broke up with his girlfriend he was hospitalized in a psychiatric hospital he's talking taking his medication how can the social worker help? And somewhere if you keep asking more questions, she might also tell you that he has slapped her a few times, that he's stolen some things. So you really want to be listening. You want to find out if the mom is actually in danger. But what she's coming for is she does want help with her son. And there's certain things, I think the terrible thing about

serious mental illness and substance use disorder is things that seem like obviously the next step like take your medication you were just in a psychiatric hospital and they gave you medication that you need to take they gave you a follow-up appointment with a therapist or a psychiatrist but the person's not going and the problem is that's not just that the kid is stubborn or um a lot of parents will say that their kid is stubborn but actually it's part of the disease of mental illness that you don't recognize that you are in fact mentally ill it's called anosognosia it's hard to spell um you want might want to learn how to spell it and learn about it and be able to tell parents that that's probably what's going on it's not that their kid is stupid

or resistant it's part of their brain that doesn't recognize they're ill that leads to not wanting to take the medication so i think it's called anosognosia a-n-o it's like not knowing okay um i think you might have heard when somebody has a stroke sometimes and their left side is paralyzed they may try to to be lifting something up with their left hand because they don't have a sense that that side isn't working but in mental illness the brain doesn't recognize that you have a mental illness so it becomes crazy to take a medication that may make you feel not great anyhow or to go back and see a psychiatrist because we have so much stigma about seeing psychiatrists or social workers

So the fights that happen between families and people who've had a psychiatric illness about take your medication, go to see the doctor, they don't go anywhere because you're both seeing the problem in a completely different way. So I suggest to social workers you really learn about this and then you help families understand it. And then it ends up being, I mean, it's a very, very hard situation. It's a difficult situation, which is why I call my book difficult. You know, partially also our mental health system is not really working for so many people. We know it's hard to get into a psychiatric hospital and it's very hard to stay and have any kind of intensive treatment. Most people, if you're in for a week, that's like amazing.

So there's structural issues for those of you who are interested in social policy. We have a far way to go to improve our mental health system. So you can explain to clients that it's it's hard what they're facing and trying to terms of trying to get their kids help is a structural problem. And if you have a parent who's just frustrated and furious at all the ways she's tried to help her child, she might want to get involved in an advocacy group and use some of her rage to try to change the laws in each state so that there are many parents who have psychiatrically ill kids really want to have more beds available in psychiatric hospitals. You may remember from your social work classes, the terrible large asylums, as we call them, Willowbrook and other

very big institutions. There were warehouses for people with retardation and mental illness altogether. And they all closed in the 60s because they were horrible. But the problem is, we were promised community mental health in every city and that did not happen and so what has happened is parents are the ones who are the default caregiver for their kids and no parent knows how to provide care for somebody who has a psychiatric illness so we need an improved community mental health system we need longer psychiatric stays where real treatment can happen We need more affordable substance use facilities. And as social workers, I mean, when the mothers come in, they want you to help their child.

So there are certain things you can help them do. You should know that regardless of income, somebody who has a diagnosed disability, like psychiatric illness or substance use disorder, is eligible for equivalent of Social Security, but SSDI, Social Security Disability Insurance. So that can take a lot of financial pressure off the parents. And you also should know that if the person has a diagnosed disability, they can be available for housing, supportive housing. And there are spaces, amazingly, in supportive housing in many cities. The problem is a lot of people rather live in their parents' house than go to a place that's more, you know, it's not as fun, it's not as good cooking. as being at mama's house, but it might really help ease the conflict in the family and certainly might protect the older person. If, and particularly

if the person's psychiatric illness is untreated, they can become violent. And often the violence is directed towards the family. And when that happens, parents can no longer have their kids living in the house. So knowing about supportive housing is really important because that will be paid for by their SSDI check and they will have a safe place to live and it doesn't have to be in their mother or father's house. That's really good information. I'm not sure that many people are aware of that especially parents right and their children listeners we'll be right back as a social worker you face unique challenges including potential threats from clients and antagonistic situations these threats are more dangerous when your home address and other

personal information is easily accessible on thousands of websites iron wall by incogni removes this content wherever it resides online, so it cannot be weaponized against you. You focus on helping others while Ironwall will keep your home and family safe. Call 844-476-6360 extension 300 or visit ironwall360.com slash social 2024 for more information. Mention Social Work Talks and Ironwall will send you a personalized risk assessment showing you which websites now have your private information. We're chatting with Dr. Judith Smith, LCSW author

of the new fascinating book, Difficult Mothering Challenging Adult Children Through Conflict and Change. Dr. Smith, you've coined the term difficult adult child to describe these challenging family dynamics. How can social workers use this concept to better understand and support families dealing with these circumstances?

Well, first of all, I don't mean difficult adult child to be pejorative or to be judgmental about the person with mental illness or substance use disorder. I came up with that name because that's how I heard mothers describing it. You know, the flip side is difficult mothering, that it's very hard to be the mother of someone who has an illness that's preventing them from being able to meet all the markers of adulthood, particularly working and having satisfying relationships, and that they're not taking the medication and getting the treatment that could improve their symptoms. So it's a very, very difficult situation. And it's difficult for the mothers because on the one hand, they want to

do everything possible to protect their kids and get them to be able to get back on being able to function as well as they can. Yet at the same time, if they're living with you or if you're having to pay for a separate apartment, it's hard. And you're feeling like, I don't want to do this anymore. I'm 70 years old. I want my peace and quiet. I don't want to be dealing with my son And then his many of these kids who move back home come with their kids. You know, they have kids already. Oh, wow. So if you like one mom described, her son came knocking on the door and he had a new baby. And he said, can we know I'm having a hard time. Can we live here?

And she said, of course, you know, every mom says, of course. I mean, that's part of our role as parents. We're supposed to be there when our kids are in trouble. But that son and his wife stayed there for 15 years. They had seven kids and they tried to evict the mother from her own house. I mean, he was a psychopath and used the court to try to get his own mother evicted from her house. So you want to be aware that kids' problems affect their mothers. Mothers take on the blame and assume they're at fault. So partially, if you like the word difficult mothering or difficult adult child, you can begin to educate, do psychoeducation to explain to your client, the mom, that she's in a difficult situation. And in fact, there's some research and there's some books that actually names it difficult parenting.

It's just like we didn't used to have the name for domestic violence. We didn't used to have the name for child abuse. We didn't have the name for elder abuse. You know, I'm hoping that difficult, I don't know if that will be the name, that somehow this dynamic will begin to be understood by professionals and by the public so that, you know, it's so hard for parents in this situation. You know, if you go to the grocery store, when older people meet each other in the grocery store or in church or anywhere, the first question that most people ask is, how are the kids? Assuming it's like saying, you know, how's the weather? And it's a nice, easy question. But for many people who have a troubled kid, you don't know what to say.

And I'm hopeful that the women who are in my group, I try to give them a different vocabulary and, you know, begin to say, you know, I have a difficult adult kid. And so right now, you know, we're in a hard spot. so when you bring this up it touches on what i want to ask you next next is about um hidden elder abuse and we've spoken about that a little bit so what should social workers be aware of in identifying and addressing elder abuse within families where adult children are facing significant issues right you know an interesting fact that most people do not know and i certainly did not know before I started this project, is the most likely perpetrator of elder abuse is an adult child with serious mental illness or substance use disorder who's living at home and is financially dependent on their parents. So, you know, when you're doing a basic biopsychosocial with an

older person, find out who's at home, find out what their situation is, and if they're not working, keep asking questions. And none of the moms ever referred to what was going on. Even though I recruited several of the moms in an elder abuse service center, none of them ever used the word abuse. So no mother is going to come in and say to you, my son is abusing me. If you begin to ask the right questions and learn how to, you might say, oh, he can be really nasty or he can be really disrespectful. He has a bad temper. So you want to really keep asking questions. What is it like if you have an adult child living in your house who's not functioning? I mean, we have many healthy adult kids who are back living home. Right now, it's the highest

percentage of young people are living with their families, again, than has ever been in history. This has to do with the price of rents, the price of going back to graduate school, the price of college. So we don't assume that any older person who has an adult child at home has a risky situation. But ask more questions. And elder abuse service centers now exist in every low-cal. You should become familiar with them, find out how you make a referral, and just really want to ask questions. And remember that older people don't like to report about their kids because they assume, one, that it means they're a bad mother if their kid is stealing from them or if their kid is yelling at them.

them. Nobody wants to think of their own son and daughter as a perpetrator or as an abusive person. And no mother wants her child to go to jail. So for many of these family elder abuse is really highly underreported, partially because can you imagine if you are a parent and you have to call the police on your kid? I mean, it feels horrible. Your neighbors are going to see it's it's a real shame inducing experience so you have to assume that it's your job to really find out what the living situation is and to see if you can help you know get that adult child maybe some services for themselves i want to pivot for a moment to my next question and that's online support groups so the online support groups you facilitate have been beneficial

for many mothers what role can social workers play in creating or promoting similar support networks for families dealing with adult children's mental health and substance use challenges well i think it would be great if social workers ran groups for parents um i first was exposed to two groups having to do with elder abuse at the organization JASA Leap, which is a large social service organization in New York City. And they offer groups for older people who've experienced some kind of abuse by their kids. Those are in-person groups. But I think as a social worker, I mean, our field was the one that invented groups. But I know from many of my students at Fordham, groups are not being used in the way that they could be used. It's complicated

about billing. Many agencies rather do individual clients. It's just easier to get reimbursed. But I would really urge social workers in settings working with older people to really think about trying to do a group practice, whether it's online or not, that these families really need support. I mean, when I run my groups, I use the book that I wrote sort of as a psychoeducation lens as part of the group. But I also do training for social workers in terms of learning what I do. I would love to have a cohort of people who are interested in doing this work. If they are, and you're listening, please contact me. I think we're going to give my contact information at the end or on your website? Yes, you can mention it now too, if you'd like. So the best way to remember

me is Difficult Mothering. So I'm Judith R. Smith at difficultmothering.com is my email. You can also reach me at Fordham, jsmith at fordham.edu. But if you just Google me, Difficult Mothering, Judith Smith, I'll come up with all of my contact information and you can go to my website which explains all that I do and that's difficultmothering.com so all you have to remember is difficult mothering and hopefully you'll find your way to me so before we wrap up I just I want to just follow up with a couple of things so what should you know next as a social worker and as a parent in this situation if you care you can elaborate on that or whatever else you may think may be relevant? Well, I'm sure there are social workers listening to this who

are parents in this situation. When I have done trainings for social workers and psychotherapists, many of the people come to the trainings are parents with difficult adult kids, because there's no place where they can talk about it. It's a shameful experience. So if you are a parent with a difficult adult child, please consider getting, joining a support group for yourself. Don't keep hiding it. I think the most dangerous part of this situation is if you can keep hiding it. And so many people feel very isolated who are in this situation, because their friends and family just don't understand. And you stop telling your friends and family. You know, Susie's still living in the house. Five years later, she's still not working.

She's still yelling at me. She's in and out of the hospital. Nobody wants to hear this. And most people don't want to share it because it's embarrassing. And you feel like maybe it's my fault. But if you're a mother and a social worker listening to this, you can get help. You can join a group that focuses on you and helps you to be able to get some strategies for how you want to move ahead in your life. Dr. Smith, thank you so much for taking the time out to talk to us about this topic. Do you have any additional final thoughts? Well, I think, unfortunately, many of our curricula and social work don't focus enough on serious mental illness. I know in my practice classes, I didn't teach it. We mostly talk about helping people who have sort of average mental

health challenges. And the other thing to be aware of is that these moms are in mourning in many ways. There's a lot of grief associated. Serious mental illness, schizophrenia arises when young people are in their late teens early 20s so you have somebody who is a valedictorian of their class somebody who was on her way to be a concert musician there's so many hopes and dreams that suddenly when the psychotic episodes start happening hospitalizations start happening The person can no longer function and complete their trajectory as a successful worker or artist. And so the mothers are carrying huge amount of grief and feelings of disappointment for themselves and for their children. So you want to help these families cope with their grief.

and you want to really learn more about this topic and don't disregard people just because they're older. They're still mothers. They're a big part of our helping network, even though they don't want to be. But because we don't have a good mental health system, they are doing an enormous amount of unpaid work and get interested in them. They need your help. Thank you so much, Dr. Smith. We really appreciate you taking the time to talk to us and be on our show today. Thank you, listeners, for tuning in to this episode of Social Work Talks as we engage in a sobering conversation on what social workers should know about families with adult children with mental illness. A link to Dr. Judith Smith's book, Difficult Mothering, Challenging Adult Children Through Conflict and Change, can be found in the show notes section of our website.

Just Google NASW Social Work Talks to find it. Again, thank you so much for listening. And for more information about this topic, visit difficultmothering.com. You have been listening to NASW Social Work Talks, a production of the National Association of Social Workers. We encourage you to visit NASW's website for more information about our efforts to enhance the professional growth and development of our members, to create and maintain professional standards and to advance sound social policies. You can learn more at www.socialworkers.org.

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