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Background and preparation of the project.
Between one in four and one in five adults will experience a mental illness during their lifetime
(Falkov,1998). At the time of their illness, at least a quarter to a half of these will be parents.
Their children have an increased rate of negative and threatening relationships that could lead to
emotional/ behavioural problems. There are well documented links between parental discord and
adverse impact on children, which, when occurring in association with parental mental illness
compound children’s needs (Canino et al., 1990; Pound, 1996). Inconsistency and ambivalence in
parenting, and marital conflict greatly increase the risk of the child experiencing maltreatment,
emotional/ physical abuse and attachment problems. The degree of risk and negativity of the
children’s experience (types of violence even if not directed at the child) affect the parenting
capabilities. We know that problematic parental relationships, especially when complicated by
mental illness have an adverse effect on children. In turn, children presenting with escalating
emotional/ behavioral problems will have further adverse impact on parenting, feeding back a
vicious circle. The most damaging factor for children’s development has been found to be the
hostility from the parent, including consistent criticism and (direct or indirect) blaming. There are
poignant anecdotal accounts by those adults who grew up with a mentally ill parent (Dunn, 1993;
Marlowe, 1996). These descriptions reveal common themes such as isolation and loneliness, guilt
and loyalty, abuse and neglect, grievances about mental illness services and the importance of
social supports throughout life. On the other hand, the effect of mental illness on parenting is
influenced by a number of other variables such as the quality of marriage, the socio-ecomomic
status and the community support networks in mental health and care (Hammen et al., 1987;
McCay & Pollard, 1996). Although the above links have been recognised for many years, it is not
generally reflected in effective, co-ordinated service provision that meets the needs of all family
members. A substantial obstacle to addressing the needs and concerns of parents suffering from a
mental illness and their dependent children has been a lack of awareness about their existence
(Jenkins & Wingate, 1994). These families’ needs are often hidden and further compounded by
the stigma associated with mental illness and the absence of physical evidence of the “illness”. In
addition, various barriers to effective joint working exist due to the specialisation in training,
practice and service development. Further, some of the difficulties relate to organisational issues,
whereas other relate to gaps in professional awareness about the relevance of working together to
meet the diverse needs of all family members (Department of Health, 1988). It is therefore not
surprising that the overlap between adult mental illness, parental status (burdened parent/s) and
child development (the burdened children) has not been addressed and that very little systematic
data is currently available on the number of mentally ill adults who are parents and on the number
of referred children whose parents are mentally ill (Blanch et al., 1994; Wang & Goldschmidt,
1994). In situations where violence has occurred in families, the presence of mental illness in a
parent/ carer may lead to the expression of hostilities toward a child (for example, parental
aggression as a consequence of psychotic delusions or parental irritability and verbal aggression
related to depression) and may impair or prevent a parent/ carer from taking appropriate steps to
ensure adequate care and safety of the children. There are therefore particular challenges which
practitioners must address in order to support parent and child victims of domestic violence
appropriately. All staff must be aware of the possibility of “hidden” or unacknowledged violence.
Practitioners must be aware of the cycle whereby domestic violence affects the mental health of a
parent whose parenting skills may thus be further impaired and who is then less able to meet the
needs of the children. Supporting parents whilst also ensuring appropriate care and protection of
children can present practitioners with difficult dilemmas. Fears about children being “removed”
can prevent parents from actively seeking help. The background of the project is based on
preparatory research on behalf of the co-ordinator as part of her PhD thesis (Bibou et al., 1997)
and subsequent projects. Specifically, the co-ordinator has been participating in a longitudinal
study assessing the objective and subjective burden experienced by the relatives of patients with
severe psychiatric problems living in the community (4 years between the first and the follow up
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assessment) this being part of a study evaluating the needs of the families in relation to the adult
mental health services offered in a designated area in Thessaloniki (Lazaridis, Bibou, et al.,
1999). From the adult study sample, those households were identified that contained children
being looked after a mentally ill parent. From the interviews conducted with the well parent
supporting the ill spouse in the community , parenting difficulties were recognized in 84% of the
spouses/ well parents. The children were reported to experience varying degrees of effect upon
their everyday functioning with health and behaviour problems being the most commonly
acknowledged area of difficulties (Bibou et al., 1999). In addition, from a pilot study on the
practitioners’ perceptions regarding these families’ needs and solutions proposed (Bibou and
Tsitsa, 1999) it was found that polarised perceptions about the parenting capabilities of those who
are mentally ill along with discriminatory views were prevalent, such as that mental illness
precludes being able to be a good parent and that children’ s removal should be a general target
for the practitioners in order to reduce risks of violence. In relation to the partnership with
England, Dr Falkov has been working on the impact of parental mental illness on the children’ s
development and has developed, as part of a larger team, a reader and a trainer (Crossing Bridges,
1998) for practitioners and managers across agencies. The co-ordinator had the chance to become
familiar with Dr Falkov’ s work during her three months’ stay in the Child and Adolescent
Mental Health Services where Dr Falkov works.
Expected impact.
The aims of the proposed project are thus formulated to a) enhance practice and improve services
for families in which mentally ill adults live together with dependent children b) to identify of
which patients are parents and which children have parents with mental health problems c) to
support the families at an early stage in order to reduce problematic relationships and risk of
potential violence. A training pack is intended for use by trainers in all agencies to promote good
practice, raising awareness, knowledge and skills amongst staff in adult mental health and
children’s services, as well as within primary care and voluntary sector services. Improving interagency is a core aim. The training pack will be based on the Crossing Bridges (Reader and
Trainer, 1998). The key points of the training are that: -mental illness is one of a number of
adversities that influence the quality of life of many families, -the health and care of children and
parents should be considered jointly,- the adoption of a life-span perspective is needed
emphasizing children’ s changing developmental needs over time and recognizing the lifelong
implications of severe mental illness for all family members- improving family communication
and early intervention are needed.
Methodology, procedure and evaluation.
The project might accomplish its aims in stages:
1. Baseline work with staff in key services such as adult mental health services; child welfare;
education; primary care; child mental health. Through this stage we want to elicit and establish
views, perceptions and needs of staff and to compare Greece and England. One basic
hypothesis is that the Greek system and practice in the understanding, the management and the
service issues regarding parenting with parental mental illness and the conceptualization of the
children’s needs would be different from that of England; that these differences would be
related to differences in formal structures and cultures; and that there would be some aspects
of structures and some aspects of cultures that might be particularly important in determining
the nature of practice in family issues regarding parenting capabilities when dependent
children are involved. For the initial evaluation, focus groups of the staff in key services could
be presented with a case outline. They will be asked to complete individual written answers to
specific questions and then to hold a loosely structured discussion of the case which will be
video-recorded and will be facilitated by a member of the research team (some of the themes
to be considered concern the plans the staff-participants might make with the family and its
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individual members, rights and responsibilities of the characters in the case study, the roles
and tasks of professionals, and the differing concerns and preoccupations of system agents
represented in groups..). In a second phase, the video could be shown (dubbed into the
appropriate language) to the participants of the other agencies and of their counterparts’ group
discussion of the case. In terms of the cross-national nature, the participants are to be asked for
their reactions and their reflections on their own system and practice in the light of what they
have heard about the other country. This discussion could be also video recorded and
facilitated by a researcher. We have to emphasize that we do not seek to make generalizations
about what “Greek or English social workers or teachers think or do” but to be provided with
accounts and interpretative repertoires that show us how the practice is reflected across
agencies and countries. The baseline work could be implemented by evaluating the family
context and the needs of families with parental mental illness by using a semi-structured
interview along the Family Burden Interview (Fadden, 1989; Bibou, 1992).
2. Provision of seminars/ training in the Greek context -through the use of Crossing Bridges-,
identifying its utility for the services in Greece. The development of training resources for
working with mentally ill parents and their children will be evaluated throughout its running
by the use of questionnaires and focus groups interviews mapping the practitioners’ change.
The methodology proposed begins with the assumption that practitioners are knowledgeable
about the conditions of their own social activity and that entering into a process of research as
changed or expanded awareness, the “right” ways to reduce the adverse effects of mental
illness on both parenting and children’s development are being actively created rather than
“discovered”. Part of the evaluation could compare teams and services who participate in the
training to similar services without the training on staff awareness etc.
3. Development of local approaches to promote better interagency cooperation (use of protocols,
liaison between services).
Timetable
1/12/2000- 28.2.2001 Identification of target groups (12-16 participants in each group). (work
with service and operational managers of all agencies along with the staff from the local
authority, health service, education). Evaluation in progress.
1.3.2001-30.4.20001 Initial evaluation and comprehensive analysis of the perceptions and the
needs of the participants. Evaluation in progress.
1.5.2001-15.8.2001 Development of a training material based on the material developed by A.
Falkov and colleagues (Crossing Bridges). Foundation Knowledge Module, Working Together
Module, Assessment, Planning and Intervention Module and Handouts. Evaluation in progress.
16.8.2001-31.10.2001 Running of the group/s
1.11.2001-31.12.2001 Overview of the Training, Evaluation.
References
 Blanch, A., Nicholson, J. & Purcell, J.(1994). Parents with severe mental illness and their
children: the need for human services integration. The Journal of Mental Health
Administration, 21 (4) 388-396.
 Bibou-Nakou, I., Dikaiou, M. & Bairactaris, K. (1997) Psychosocial dimensions of family
burden among two groups of carers looking after psychiatric patients. Social Psychiatry and
Psychiatric Epidemiology, 32, 2 (February), 104-108.
 Canino, G., Bird, H., Rubio-Stipec et al. (1990) Children of parents with psychiatric disorder
in the community. Journal of the American Academy of Child and Adolescent Psychiatry, 29,
398-406.
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 Department of Health (1988) Protecting children: A guide for social workers undertaking a
comprehensive assessment. London: HMSO.
 Dunn, B. (1993) Growing with a schizophrenic mother: A retrospective study. American
Journal of Orthopsychiatry, 63 (2) 177-189.
 Fadden, G. (1989) Pity the spouse! Depression within marriage. Stress Medicine, 5, 99-107.
 Falkov, A. (1998) (Ed) Crossing Bridges. Training resources for working with mentally ill
parents and their children. Department of Health, London.
 Hammen, C., Adrian, C., et al. (1987) Children of depressed mothers: Maternal strain and
symptom predictors of dysfunction. Journal of Abnormal Psychology, 96, 190-198.
 Jenkins, S. & Wingate, C. (1994) Who cares for young carers: Their invisibility is the first
problem to be addressed. British Medical Journal, 308, 733-734.
 Lazaridis, B., Bibou-Nakou, I., Georgopoulou, A. & Papathanasiou, A. Family Burden: A
measure of prevention among families caring for psychotic patients. WPA Regional Congress
“Preventive Psychiatry” 24-28 February 1999, Athens.
 Marlowe, J. (1996) Helpers, helplessness and self-help: “Shaping the silence”: A personal
account. In: M. Gopfert, J. Webster & M.V. Seeman, Parental Psychiatric Disorder:
Distressed Parents and Their Families. Cambridge University Press.
 Pound, a. (1996) Parental affective disorder and childhood disturbance. In: M. Gopfert, J.
Webster & M.V. Seeman, Parental Psychiatric Disorder: Distressed Parents and Their
Families. Cambridge University Press.
 Wang, A. & Goldschmidt, V. (1994) Interviews of psychiatric inpatients about their family
situation and young children. Acta Psychiatrica Scandinavica, 90, 459-465
I.Bibou-Nakou
Education-Studies
 1976-1980: Faculty of Philosophy, Department of Psychology, Education and Philosophy,
Aristotle University of Thessaloniki, Greece.
 1981-1983: MSc in Clinical Research, Victoria University of Manchester, Faculty of
Medicine, Manchester England.
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 1988-1992: PhD (Clinical Psychology). Family burden in the family context of psychiatric
patients living in the community. University College London and Aristotle University of
Thessaloniki.
 1990: Training in the Expressed Emotion Index (Camberwell Family Interview). Newcastle
upon Tyne (2 months).
 1999: Child and Adolescent Mental Health Services, South London and Maudsley NHS Trust
3 months of training.
Teaching and clinical experience
 1992-2001-Senior Lecturer, Department of Primary Education, Aristotle University of
Thessaloniki, Greece.
 1991-Clinical Psychologist, working in the Community Center for Single-Parent Families,
Thessaloniki.
 1984-1988- Clinical Psychologist, working in the Community Mental Health Center
(Thessaloniki), Unit of Psychosocial Rehabilitation for Young people suffering from
psychosis.
 1985-1988. Research Assistant, Faculty of Philosophy, Department of Psychology, Education
and Philosophy, Aristotle University of Thessaloniki, Greece.
 Research
 1984-Research Program for the Psychosocial well-being among school-aged children (1st
University Psychiatric Clinic of Athens).
 1988-1991-Assessment and Intervention to families caring for members with severe
psychiatric problems (Unit of Psychosocial Rehabilitation, Thessaloniki, and Department of
Psychiatry, Guy’s Hospital, London, Funding by the British Council and UCL).
 1992-1994-Psychosocial and Occupational rehabilitation of migrants: The case of people
moving from ex-Soviet Union and Albania (E.E.C in collaboration with the Department of
Psychology, Thessaloniki, Greece).
 1995-(ongoing) Emotional/ Behavioural problems in school-aged children. Epidemiological
study. Correspondence among Child, Parent and Teacher Reports.
 1994/1995 & 1998/1999. -Epidemiological study of families with psychiatric patients living in
the community (in collaboration with the State Psychiatric Hospital, funding by the Greek
National Health System Research Committee ).
 1997-Pilot research program on teacher education for children with special needs (E.E.C. in
collaboration with the Department of Psychology, Thessaloniki, Greece).
Relevant Publications and paper presentations
 Bibou-Nakou, I., Dikaiou, M. & Bairactaris, K. (1997) Psychosocial dimensions of family
burden among two groups of carers looking after psychiatric patients. Social Psychiatry and
Psychiatric Epidemiology, 32, 2 (February), 104-108.
 Bibou, Ι. (1999) Family Caregiving context: Recent Conceptualizations of the Family Burden.
Scientific Committee of the Department of Psychology, Aristotle University of Thessaloniki,
Vol. 3, 93-115, Thessaloniki.
 Bibou, I (1999) Parental mental illness: impact on the children and counseling principles in the
families with dependent children. Greek Review of Counselling, 4, 23-47.
 Ziogou, E. & Bibou, I. Professional Burden among the psychiatric nursing staff:
conceptualizations and training. Journal of Nursing Issues (Νοσηλευτική), 37, 1, 62-71.
 Bibou, I et al. (2000). Strengths and Difficulties in school-aged children in relation to the
Family Psychosocial Functioning. Journal of Mental Health and Psychopathology of children
and adolescents, Volume 3 (Spring), 1-29, Kastaniotis Editions, Athens, Greece.
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 Bibou-Nakou, I., A. Stogiannidou, & G. Kiosseoglou (1999) The relation between teacher
burnout and teachers’ attributions and practices regarding school behaviour problems. School
Psychology International, 20, 2, 209-217.
 Bibou-Nakou, I., Kiosseoglou, G., & Stogiannidou, A. (1999) Elementary teachers’
perceptions regarding school behavior problems: Implications for school psychological
services. Psychology in the Schools 37 (2) 2000, 1-12.
 Lazarides, B., Bibou, I., Tasiou, E., Tsiroyiannis, J. & Ierodiakonou, C. Occupational and
economic burden of supporters of psychotic patients living in the community: evaluation of
satisfaction with provided services. IΧ Conference of the South-East European Society for
Neurology and Psychiatry, 23-26 September 1992, Thessaloniki.
 Lazarides, B., Bibou, I., Benos, A., Iacovides, A., & Ierodiakonou, C. Community mental
health services: needs assessment of families with psychotic members. 4th International
Conference on Innovations in Community Psychiatry, International Institute of Crisis
Intervention and Community Psychiatry, University of York, 23rd-25th March 1994.
 Syngelakis, M., Bibou, I., Papathanasiou, M., Chatzaridou, A., Kiosseoglou, G., & Vidalis, A.
Assessment in the family support system of transplant patients. 11th Conference of the SouthEast European Society for Neurology and Psychiatry, 1997.
 Lazaridis, B., Bibou-Nakou, I., Georgopoulou, A. & Papathanasiou, A. Family Burden: A
measure of prevention among families caring for psychotic patients. WPA Regional Congress
“Preventive Psychiatry” 24-28 February 1999, Athens.
 Bibou, I. Parental psychiatric disorder: perceived changes in the parental roles and the mental
health needs of school-aged children. VI European Congress of Psychology, Rome 4-9 July
1999.
 Bibou-Nakou, I., Hatzidimitriadou, E., & Karanikos, A. (1995). Invited Symposium: Process
of personal and social coping in moving and non-moving minorities. IV European Congress of
Psychology, 2nd-7th July, Athens, Greece.
 Bibou, I., Kiosseoglou, G. et al. (1999) Factor structure and correlates of ratings of inattention,
hyperactivity and conduct problems in a sample of school-aged children. 5th European
Conference on Psychological Assessment, August 25-29, University of Patras.
 Bibou-Nakou, I., Stogiannidou, A., Kiosseoglou, G. & Figou, E. Elementary teachers’
representations regarding school misbehaviour problems. 7th European Conference for
Research on Learning and Instruction, August 26-30, 1997. Athens, Greece.
 Bibou- Nakou, I. (1999) Elementary school teachers’ representations regarding school
problem behaviour: “problem children in talk”. The 18nth International Human Research
Conference, 26-29 July 1999, “Qualitative Research: Unity and Diversity”, University of
Sheffield, England.
 Bibou- Nakou, I. et al. (1999) Developmental patterns of elementary teachers’ perceptions
related to school adjustment problems. 5th European Conference on Developmental
Psychology, Spetses, September 1-5, 1999.
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