In Reply: Dr. Erickson and his coauthors remind us of the significant impact on a child of the loss of contact with a parent. The "best interests of the child" standard may simply be translated into the removal of a child from the danger or harm, actual or assumed, of living with a parent who has mental illness. A child's attachment to a parent may not be given the same weight accorded to the belief that treatment noncompliance increases the risk of abuse or violence by parents against children or that treatment compliance improves parenting capacity.
My recommendation is for research, not for using child custody as leverage. In my clinical experience and that of my colleagues in Massachusetts, a parent's treatment recommendation is often included in a child welfare service plan (personal communication, Kinscherff R, January 25, 2005). Judges in such cases make decisions about children's care on the basis of the compliance of parents with these service plans. Likewise, in divorce cases, judges make decisions on the basis of compliance with orders for treatment when making visitation, custody, or removal determinations. Hemmens and associates (1) noted that in 1999, statutes in 26 states allowed the restriction of the parental rights of persons with mental illness, an increase from 22 states in 1989. They concluded that the restriction of family rights is likely to impose a "real and significant burden" on individuals with mental illness. Although I appreciate Dr. Erickson and his coauthors' "caution against the adoption of child custody as a routine method of enforcing treatment compliance," I suspect it comes too late; this form of leverage is already undoubtedly in widespread use.
Research is essential to determine the prevalence and circumstances of the use of child custody or contact as leverage, as well as its impact and effectiveness. Although reunification with children may motivate parents into treatment, removing children from their care does not always enhance parents' treatment participation or progress. As one mother with mental illness explained, "My heart got ripped out when they took my kids. If I had my children I would've tried that much harder. I could not put my whole heart into therapy because I was so worried about my kids all the time." Federal policy and local practices may ignore the cyclic nature or potential for recurrence of many mental illnesses. A parent with mental illness may appear "better" or "worse" depending on the timing or course of an evaluation for the Court. The impact of the threat of losing a child coupled with the stress of being evaluated would seem likely to exacerbate a parent's illness. The evaluator then reports to the court on the parent's worst functioning, rather than on the parent's capacity to provide sufficiently for the child.
If community living and optimal participation in all chosen life roles are the goals of treatment and rehabilitation for individuals with mental illness (2), it is our responsibility to determine effective strategies for achieving these goals, rather than to employ untested policies and practices that serve as barriers to recovery for parents and cause unnecessary harm to children.