“Flying over the radar”: Changing practice to support children and families where a parent has a mental illness

“Flying over the radar”: Changing practice to support children and families where a parent has a mental illness

Rose Cuff and Brad Morgan
26 February 2015

This webinar described ways to foster systemic change in practice to improve outcomes for families where a parent has a mental illness.

Audio transcript: “Flying over the radar”: Changing practice to support children and families where a parent has a mental illness

Audio transcript (edited)

Webinar facilitated & speakers introduced by Rhys Price-Robertson

PRICE-ROBERTSON

Good afternoon everyone and welcome to this CFCA webinar, "Flying over the radar": Changing practice to support children and families where a parent has a mental illness. My name is Rhys Price-Robertson and I'm a researcher and PhD candidate at Monash University where I'm conducting qualitative research with families in which a father has a mental illness. Until recently, I was a Senior Research Officer in the CFCA Information Exchange. Today, we're going to be talking about the topic of parental mental illness, looking particularly at the ways in which service providers can and have been working towards improving outcomes for families where a parent has a mental illness. The webinar will provide participants with an overview of the work undertaken at a national level to implement practice change and to develop resources for the workforce and for families.

This webinar is part of a series of resources that CFCA is releasing on supporting families where a parent has a mental illness. A CFCA paper on fatherhood and mental illness is already available as is a number of short articles, and we will send you links to these after today's presentation. Before I introduce our esteemed speakers, I'd like to acknowledge the traditional custodians of the land in which we are meeting. In Melbourne, the traditional custodians are the Wurundjeri people of the Kulin nation. I pay my respects to their elders, past and present, and to the elders from other communities who may be participating in this webinar today.

It's now my pleasure to introduce today's two presenters, both of whom are heavy hitters in the field of parental mental illness. The first is Brad Morgan. Brad is the Director of the Children of Parents with a Mental Illness national initiative, which is more commonly known by its acronym, COPMI. COPMI is administered through the Australian Infant, Child, Adolescent and Family Mental Health Association. Brad trained as an occupational therapist and has experience in public health, mental health promotion and prevention, workforce development and early childhood programs. In his current role, Brad works with the COPMI team to partner with family members, professionals and organisations to support the development of national strategies to improve outcomes for children and families where a parent is experiencing mental illness.

The second presenter today will be Rose Cuff. Rose is an occupational therapist who has worked in child, adolescent and adult mental health services since 1986. Since 1995, she's focused specifically on the area of supporting families where a parent has a mental illness through direct clinical practice, through creating and implementing peer support and group programs, and through developing resources and conducting training and research. Since 2007, Rose has worked as the state-wide foordinator for the Families where a Parent has a Mental Illness strategy, or FAPMI, which is based at the Bouverie Centre in Melbourne. The FAPMI strategy is a government-funded initiative aimed at building capacity in services to promote better outcomes for these families.

Now, I need to alert you to some brief housekeeping details before I hand over to Brad and Rose. One of the core functions of the CFCA Information Exchange is to share knowledge, so I'd like to remind everyone that you can submit questions via the chat box at any time during the webinar. There will be a bit of time at the end for questions, so we'll try to respond to as many of these as possible. We also want you to continue the conversation we begin here today. To facilitate this, we'll set up a forum on the CFCA website where you can discuss the ideas and issues raised, as well as share some of your experiences. We'll send you a link to this forum later this afternoon. Please remember that this webinar is being recorded and that the audio, transcript and presentation slides will be made available on the CFCA website in due course. Okay, that's it from me. Now I'll hand over to the first of today's speakers, Brad Morgan.

MORGAN

Thank you, Rhys. And I'd like to welcome everyone to this afternoon's webinar as well. Rose and I will be talking about the work that both of us have had the opportunity to be involved with through the COPMI initiative, and that's through the national program and the FAPMI initiative or strategy, which is in Victoria. While both initiatives have different names, the focus of our work is on the same population group and that is children under 18 and families where a parent experiences mental illness. The focus of my presentation will be on the national context and the learnings that we have had since the initiative started almost 14 years ago. Rose will talk about the Victorian experience of implementing the FAPMI strategy. In our presentation today, you'll probably notice that many of the learnings we talk about are consistent and this isn't a coincidence. The work we will describe has been a result of partnerships and relationships that we've developed locally, nationally and also internationally.

Firstly, I would like to acknowledge the passionate team that I work with at the Australian Infant, Child, Adolescent, Family Mental Health Association who I've had the privilege of working with. I'd also like to acknowledge the work of Elizabeth Fudge, who was the Director of the COPMI initiative from 2001 until 2012 and whom worked extremely hard to drive this initiative forward and establish international, national relationships that continue to assist many of us to progress this work today. I'd also like to acknowledge the support provided by the Australian Government, who've provided funding to Scope, establishing support in the initiative since the original Scope project commenced in 1999. Another group I'd like to acknowledge today is the family members that our team has the privilege of working with across all areas of our work. The saying "Nothing for us without us" resonates strongly in our team and we value the passion, enthusiasm and honesty of family members who are at the centre of the work we do.

So to get started, I thought I'd provide a quick background to what we know about children of parents with mental illness and the reason why this is a group of interest in the community. What seems to be of particular interest in the community is the question: Does mental illness run in families? The short answer to this question is, it depends. There's a large amount of research occurring locally and internationally, and we're learning more and more from studies on prevalence, risk and protective factors, genetics, neurobiology, trauma and research in the determinants of health. For this reason, this area of work draws on multiple theories and conceptual understandings. There is no single grain theory that underpins the work occurring in this area.

A major reason for the focus on this group is the population of children living in families where a parent has a mental illness. Historically, there's been very little data regarding the number of children of parents with mental illness in Australia. While this is still the case in many organisations, we do have a number of prevalence estimates that have been undertaken in this country. A fairly widely accepted estimate is that around 23 per cent of Australian children have a parent with a mental illness and so that's around one million children. This appears to be consistent with estimates overseas.

Another reason for the focus on this population group in the community is that this population group is recognised to be more likely to experience social, emotional, developmental and education difficulties, as well as being significantly high-risk of experiencing mental illness. The risk is estimated to be two, three times higher than children who have a parent with a mental illness than those that don't. Before I continue, I'd like to highlight that not all children will experience difficulties. Many children are thriving and can develop strengths from their experience of living in a family where a parent has a mental illness. For this reason, I think it can be helpful for everyone to conceptualise children's needs forming across a continuum, ranging from thriving and well at one end, and then we move across to children who are at-risk, to children at the other end – living in environments where their wellbeing or safety is of major concern and are possibly in contact with services such as CAMHS or Child Protection Services.

The other thing to point out is that children are moving across this continuum back and forth at different times of their life depending on their life context. So when you might see a child in infancy, they might be at one area or end of that continuum and move across, back and forth, before they turn 18. So what are some of the things that influence child and family wellbeing? Once again the answer is, it depends. Every child, parent and family is unique, and children in the same family often have different responses and outcomes as well. In regards to parental mental illness, we know that specific diagnosis can provide some predictors of potential child outcomes. For example, children of parents with depression do have a significantly higher likelihood of experiencing depression themselves.

However, the research indicates that parental diagnosis is not as strong as associations with other factors such as the duration and intensity of symptoms that the parent experiences and how they impact on parenting and the parent-child relationship. For example, a very brief but severe episode may have less impact on children and families than a moderate but long-term episode that has accumulative impacts over a longer term in the child's life. Other things that many families and professionals identify as having an impact is the actual impact of the treatments for mental illness themselves. We do know that there is a real juggling act in trying to balance the impact and side effects of medications and how to have lower impacts on the parenting capacity and the parent-child relationship.

We also know that mental illness is also often part of a range of other issues related to relationship problems, social and financial challenges and broader determinants of health. So when thinking about the impact of these issues on individuals, we also need to recognise that they do have flow-on effects to the parent-child relationship and children. And for many parents, we also know that they may have had their own experiences of trauma and disadvantages when they were children and that these may have also been experienced across multiple generations. We also know that other vulnerabilities such as drug and alcohol, family violence, homelessness and mental illness do often co-occur, and there's a lot of research demonstrating that these children are particularly vulnerable when there's accumulation of these issues occurring in families.

So I've given a bit of an overview of some of the challenges and issues that families experience, but I thought it would also be important to point out that a lot of work has been focused on the processes that can support children to develop and thrive in the context of mental illness. Some of the processes that have been demonstrated in research is a commitment to support, maintain and strengthen parental capacity and the parent-child relationship. This is evident in parents prioritising and really working hard to maintain their relationship and their parenting responsibilities in the context of the many challenges that they face. Another powerful process is when children and families can work towards mutually understanding what they have experienced in relation to parental mental illness. For example, this is when parents and children can have those, often in conversations, over time, where they can talk about their experiences and try to make sense of those.

And with the goal of, I guess, helping children to develop a sense of hope about the future. That these are temporary issues that can be separate to them. But also that they aren't responsible for causing or resolving the issues that the parent experiences. The other process that can support children is their active involvement in the community, such as opportunities to have positive experiences of education, play and involvement with community groups. The other area is obviously having a supportive network of relationships both within and outside of the community. At good times, these relationships are supportive for their participation and wellbeing but also these relationships enable responses and supports to be activated when children do experience problems. So it's really about having someone looking over and supporting children when needed. And that's also about supporting and helping children to identify the right supports when they need it – that might be just activating natural supports that are within the child's network, to actively accessing services that might require specialist support, such as mental health services and health services and child protection services.

Another powerful process for families is their sense of hope about the future. And while hope is obviously probably more based on my conversations with families and parents, I think there is a strong sense that parents hope for their own future, and their own recovery is strongly intertwined with their hope for their children's future. If they're feeling hopeful about the future for their family and their children, I think their own hope is further strengthened by that process. I think that's an important principle that all of us can apply to our work and practices around the generation of hope for children, parents and families.

I'll move on to talk a little bit about some of the interventions and evidence that have emerged particularly over the last two decades. We've seen a number of prevention, interventions and strategies emerge that have been designed to improve or prevent difficulties in children of parents with a mental illness. A recent systematic review and manner analysis examined the effectiveness of these interventions and found that selective interventions or selective prevention interventions are effective at decreasing the risk of mental disorders in children. They can be effective at reducing the likelihood of children developing the same illness as their parent by around 40 per cent.

I won't go into detail on interventions here, but we have been working on how some of these interventions can be applied in the Australian context. Rose and I will talk about one example later in this webinar, and, not surprisingly, the strongest interventions appear to support the protective processes that I've just described on the previous slide. These tend to be targeted either towards the parent on their own, towards parents as a couple, or parents and children together. So I've just provided a very brief background to the current context and evidence around children of parents with a mental illness. But I would just like to point out that if you are interested in learning more, I'm sure there'll be lots of articles and resources available on the CFCA website after this webinar. I'd also like to point out that in 2012, the COPMI national initiative sponsored a Medical Journal of Australia supplement, which has a number of articles to provide a good summary of evidence and thinking in this area, including some of the interventions as well. These articles can be accessed for free on our website, which will be listed at the end of this webinar.

The next part of my talk will be about the COPMI national initiative's response and strategies that have been applied over the last 15 years. However, before I do, I thought it was important to highlight that the focus on children and families where a parent has a mental illness has a long history that goes back a number of decades, well before the establishment of the national initiative. The foundation of this work has been driven by a number of champions who, through either lived experience or professional practice, have been able to highlight the needs, strengths and challenges experienced by parents with a mental illness, their children and families.

In Australia, the 1990s saw an increasing national focus on children of parents with a mental illness. On screen, you will see a couple of quotes taken from some studies and work that were undertaken in the 1990s. A key finding of the work in this era was looking at the finding that children of parents with a mental illness were flying under the radar in the community and in the services that were working with parents. So in a sense, children and the needs of children were invisible, and there were limited mechanisms for children of parents with mental illness. Because this metaphor of the invisible child has been used quite a lot, I'll be using this as a helpful way to conceptualise the principles underpinning our work through the COPMI national initiative, and this'll be reinforced by the work that Rose will be talking about through the FAPMI strategy.

I'll be using this concept of the invisible child over the coming slides with the intention of helping everyone reflect on how visible children are in the context of parental mental illness in our organisations, including the things that contribute to children being invisible, as well as some of the processes that can increase the visibility of children. Something I think we all need to start with and start thinking about in general is: what do we mean by children being invisible? Everyone has different understandings of this so it's something that we all need to work on developing, and developing a common understanding of what we actually mean by what is a visible child.

For the purpose of my discussion, my meaning does not necessarily refer to children being physically visible in services although I do recognise that this does have benefits. My meaning relates to what we know and understand about children's strengths, their vulnerabilities and the context of their lives including the things that influence their wellbeing and development, such as their relationships both in families and in the community, and their access to support networks that strengthen their development and wellbeing. So the theme of our webinar today was looking at flying under the radar to flying over the radar. I thought to give a bit of context, for children to be visible, there needs to be an alignment of many different levels of work to support and highlight the visibility of children across different levels within organisations to support practice change, and this requires a conscious effort.

Because these levels are so big, I obviously can't give you too much detail around each of these levels because I'd be talking for quite a long time. So I'll give you a bit of a snapshot. But I'd really like people just to have this opportunity to think about these different levels and where they sit within this level, I guess, of systems that influence practice change and what they can do within their network of relationships and supports and their role to increase the visibility of children. I'd also like to point out that we use this tool, or this conceptual tool, in our work, and find that it helps the people that we worked with to think more systemically about the different layers of work that need to occur to support practice change. Part of that is also thinking about the different levels of readiness at different levels of this system that we're talking about today, and recognising that often the different levels of readiness are different across all of these, even within the same system or organisation.

So the first layer I'm going to talk about today is the systemic level. And this describes things such as policy, legislation and then broader policy standards that influence how visible the children are and the services that are delivered through policy initiatives. In Australia, we've seen a positive movement towards increasing the visibility of children through a number of major policy and frameworks. Some good examples of this include the National Framework for Protecting Australia's Children and mental health workforce standards. At a state level, we're starting to see the needs of children and parents articulated in different pieces of legislation such as mental health acts, as well as in policy, reports and strategies that are being developed around vulnerable children. Rose will be able to talk a little bit more about those in her strategy, particularly in the Victorian context.

I think a common thread among many of these policy documents and frameworks is recognition now that children's wellbeing and safety is everyone's responsibility, irrespective of whether people are working in adult, child or family focused services and that we all play a role. From a practice change level, I'd just like to highlight some of the resources and, I guess, strategies that we've applied at the COPMI initiative to support practice change at a systemic level. Some of the major things are, obviously, a contribution to some of the policy and frameworks that have been developed over time, such as the National Framework. Late in 2009, COPMI sponsored a systems change report, which articulated different approaches that services, organisations, states and territories were using to implement organisational changes to support children of parents with mental illness. From the COPMI initiative, we also have a state government Mental Health Department Reference Group, which helps us to work together to see where different states and territories are able to apply some of the learnings and principles to support practice change at a policy level.

The next layer that I'll talk about is at the organisational level. There are a number of services that we can use, I guess, as exemplars that have made significant changes to improve the visibility of children and their needs. Rose will give you some good examples in the Victorian context, so I won't go into significant detail other than to say that some of the things that are helpful for organisations is obviously recognising children and that children should be articulated in an organisation's mission and that needs to happen at a peak level. The other areas of work is moving down to things like policies and procedures, and how this relates to the actual work and practices of the staff that are in the organisation. Also, to the finer detail of things, such as enduring things like job specifications for staff, staff selection processes and funding models and cooperate strategies that aim to ensure that practitioners are keeping children and families in mind.

From a COPMI level, some of the strategies that have developed over time – I guess, with us, because it has been a 14 year project, some of the work, early work, was developing a document called, "Principles and actions for supporting children and families where a parent has a mental illness." This document articulated some core principles and some broad actions that services, both in adult, child and family services, could apply to respond and support children of parents with a mental illness. More recently, we have been working on the experiences that states, territories and organisations have had in regards to applying some of those principles and actions. So we've developed some implementation guidance materials that we're currently piloting. They look at, "How do we support organisational change?", "What have we learnt from the organisations that have done this well, as well as some of the organisations that have had some real difficulties of pushing this agenda forward?"

The next level I'll discuss is at the supervision level. We do know that this worker-supervisor relationship has a powerful potential to promote child awareness. Or inversely, child invisibility in practice in our work, working with professionals, organisations and supervisors, we do know that there is a lot of pressure both on workers and supervisors at the moment and for quite a long time around developing skills. Quite often, professionals don't have access to supervisors outside of the performance management context, so there isn't often a space to unpack the work that they're doing, which is quite new for a lot of services, particularly in the adult space. So through regular and consistent supervision, we know that when supervisors ask questions about parenting and children there are prompts that workers can use to think about children's needs, and then explore that in further detail.

From a resource level, we're fortunate to receive some support through the Child Aware initiative to develop a child-aware e-learning course that aimed to assist supervisors in adult services including mental health services, drug and alcohol services, homelessness services and a number of others to really think about some of the challenges of providing supervision in adult services and how they can better support workers to focus on the needs of children. The next layer down I'll talk about is the workforce or frontline service level, which is really dependent on where the profession is working. It could be in adult, child or family space. So there are different principles. but underlying this, there is a common value in the work and intention of the work. I think one of the major learnings that we have had is that across all of these services is the needs of adults, when they are experiencing mental health problems or other associated difficulties, can often dominate the focus of an intervention delivered by any of these services and it requires a deliberate and conscious effort to attend to the experience of adults as parents and explore the needs of children.

To the extent where workers have to prioritise and make decisions about prioritising the time to actually have conversations about parenting and children – it just kind of doesn't happen automatically. So I guess a lot of the work that we've been looking at is about, "How do we support conversations about children and the role of parents and supporting the safety, wellbeing and development of children in routine practice?" And this is across all levels of intervention ranging from assessment, to therapies, to follow-up, and all in between. So I guess at a practice level, we do also know there is a continuum of child visibility, ranging from not being identified at all, to collecting basic information about children such as names and aged, to asking about problems or waiting for parents to raise those problems, to the end, where we would like to see, which is where there is a mutual understanding between both parents and the professionals they work with about the child, their strengths and vulnerabilities, and knowing the context in which children live.

A method that we're currently working on to support these conversations to happen as part of routine practice is a "Let's talk about children" program. Rose will be talking about this in a little bit more detail. I'll go into more detail about that later in the webinar. I'd just like to highlight from the COPMI national initiative perspective, a lot of the work that we have been working on has operated across a continuum, and I think that has happened earlier on. A lot of work was focused on raising awareness and providing services with basic principles to support children and families, and a lot of this work was originally focused on adult services. Since that time, we've seen the emergence of a number of evidence based programs and interventions. So as time progresses, we are seeing us work towards, "How do we apply evidence-based interventions into practice?" I think we can see that continuum moving from raising awareness to actual practice change, and we're in the middle of that process. It's quite exciting to see what's been taken up and the enthusiasm of the workforce using some of the interventions that have been developed.

Now I'll move on to the parent-child level and I'd just like to point out, because the focus of this webinar is on practice change, I won't be talking about the parent-child level significantly today other than to point out that similar to the continuum concept I've been talking about at the other levels, is that there are a range of resources for both parents and children, which are on the following slide. That aimed to both raise awareness and provide resources for parents and children at that level of raising awareness, to moving across to things that they can apply. That might be evidence-based strategy, such as talking with their children about what's been happening, setting up for the care of children when things might not be going so well for the parent, and a range of other strategies that can be helpful for them.

Once again, I thought it'd be just important for me to go back to talking about our lived experience partnerships that are at the centre of the work of the COPMI national initiative. For us, I can't underestimate how important family members have been in working with us across all of the layers of the work that we try to look at, and that's what I've been describing on the previous pages. We have been fortunate to have a great group of family members that help us to understand what is needed and to drive the layers of work forward. This has been an important lesson for us, but it's also an important lesson for all services that need to strive towards active partnerships with family members at all levels, described on the previous slides. Now I'll now hand over to Rose, who'll talk about the FAPMI strategy in Victoria, which is one examples of the many strategies occurring across Australia and improved outcomes for children of parents with mental illness.

CUFF

Thanks, Brad. It's a great pleasure to be here talking with you all about issues that I'm very passionate about. I'm going to spend a bit of time describing some of the work being undertaken here in Victoria to bring about a change in practice. That's a slow and steady undertaking – it's a bit like the tortoise, not the hare. I'll briefly describe the FAPMI service development strategy that Brad's mentioned and the reform context within which it sits. I'll also describe the large-scale trial of an early intervention approach, which Brad's mentioned called, "Let's talk about children", originally from Finland. And then I'll also talk about the recent 2015, this year, publication of FAPMI practice standards, which we're very excited about.

The context that I'm referring is multilayered, complex and constantly changing. I'm sure many of you listening also work within a very complex place. Here in Victoria, it includes a new Mental Health Act embedding the recovery-oriented framework under renewed and strengthened focus on vulnerable children and families. The inquiry conducted into vulnerable children and families in 2012 resulted in a range of recommendations in Victoria, and this is designed to drive the broad base change required across government and in the community to achieve better outcomes for children over the next decade and beyond. I'll talk a little bit about the Mental Health Act in Victoria, just because it's been a very powerful – I suppose, a change agent in bringing about changing practice.

The Mental Health Act includes a number of principles – there's 12 overall – to guide the provision of mental health services. Three of these specifically direct a focus on children of clients receiving mental health services and they're on the slide. This provides some rationale and even, dare I say, leverage to change the way parents and their children are identified and offered support and entry to a mental health service. The new Act in Victoria also has provisions around supported decision making and client-centred care, including the nominated person in care provision. This acknowledges in legislation that children and young people may in fact be taking on roles with caring responsibilities. Again, this legislation can assist in driving further change in practice and the re-orientation of adult services to be child and family inclusive, collaborative and, importantly, to bring the child into the space and be visible, as Brad's talked about already.

It's my turn to do a few acknowledgements. The FAPMI strategy is funded by the Department of Health and Human Services here in Victoria and there are senior clinicians employed as FAPMI coordinators as 11 of our 22 area mental health services. The strategy was launched in 2007 and is a unique initiative in Australia and I reckon internationally, actually. The Bouverie Centre is responsible for the coordination of the strategy or the implementation of the strategy. The Bouverie Centre, where I'm based, is part of La Trobe University and combines clinical family therapy, model development, academic teaching, qualitative and quantitative research, workforce development and community education in one integrated service. It's a fantastic place for me to be, particularly around learning about implementation, which is the way to go.

I'd like to acknowledge Dr Mel Goodyear, who's currently a research fellow at Monash University, School of Rural Health and an adjunct researcher at the Bouverie Centre. She's a principal researcher of a randomised controlled trial of apparent recovery intervention, which will talk about "Let's talk about children". Mel has made and continues to make a very significant contribution to the research in this field, both here and overseas. Finally, I'd like to thank and acknowledge the incredibly skilled and passionate team of FAPMI coordinators across the state, the many practice champions who support them, and the many people with lived experience who inform our work.

The overall aim of the FAPMI strategy is to reduce the impact of parental mental illness on all family members, especially dependent children, through capacity building, systemic and sustainable change. The actual initiative – we use the word "families" intentionally at the time in 2007 to encourage a systemic response. It grew out of a three year – a lot of work – but most recently a three-year pilot evaluating peer support programs, most notably PATS, Paying Attention To Self and CHAMPS, Children and Mentally Ill Parents in Victoria. It was a conscious move on the part of the government to invest in a capacity-building service-development initiative rather than purely direct service initiative. This has been critical in the work that's been undertaken in Victoria.

The value of peer support for children is not in doubt, and I'll return to this later, but there was and always is a need for service improvement implemented in a coordinated, sustainable way. The decision to locate the positions and embed them within public mental health services was a highly strategic one and it shone a light fairly and squarely on mental health to address their practices in regard to this population. The scope of the strategies is very wide ranging and these are strongly influencing roles. The FAPMI positions act as boundary spanners, to quote my manager Brendan O'Hanlon, across service sectors and have a clear focus on supporting change in practice. I believe the strength of this initiative lies in the recurrent funding of the positions, the go-to nature of these roles, that they operate within ideally an authorising environment and the depth of the relationships that have been fostered over many years – well, since 2007.

The strategy has three objectives, which are on your slide there. Increasing the capacity of mental health services, to provide a family focused response, increasing the capacity of basically everybody else that works with families, which we call "network partners", to recognise and respond to FAPMI and to establish and strengthen the networks and support structures. The work, as I said, sits within a broader framework of adopting family inclusive approaches, such as single-session family consultation broadly, family sensitive practice, multiple family groups and many more. But the real challenge here has been in making, as Brad has said, children and parents and families visible. Particularly, working with the concept of families tends to bring to mind family of origin rather than family of procreation, and the real challenge is bringing the children into the debate.

I also want to mention the broadening the lens beyond mental illness, and, as I said, Brad has talked about the complexity that exists for many families. We initially focused on working primarily with adult mental health services. The strategy was enhanced in 2008 to a bit more EFT and to broaden the reach of the work into the AOD sector and beyond in recognition of complexity. The Child Death Review Reports and Recommendations conducted by the Office of the Child Safety Commissioner here in Victoria consistently make the link to vulnerability and the coexistence in particular of family violence, parental substance misuse and mental illness. Certainly more recently, with Rosie Batty's debates and her talking openly about family violence, it's coming back into the spotlight. It's important to talk about mental illness in that context as well.

Recommendations consistently state the importance of partnerships in protecting and caring for children in the critical issue identifying parents and dependent children. This is consistent with the Commonwealth Government's child aware approach in, as Brad said, protecting children is everybody's business. I'm going to talk a bit more about changing practice or practice change. This slide really just very briefly summarises what we've been doing in terms of working with adult mental health service worker practice alongside organisational practice. There was a starting point for the work and all along we have taken an implementation approach to work systemically to drive change. I'm going to spend a bit of time talking about some examples of changing practice in the following slides.

Brad and I have talked about implementation so you'll probably get a bit sick of us talking about it, but it's been a driving force for us and many people who work in this field. It's a key vehicle for changing practice and making it sustainable, which is what we all want. The FAPMI strategy has worked with individuals and organisations to move away from the providing of just training or, as somebody once said, "A train and hope approach", to adopting evidence-based methods in an implementation approach, establishing readiness, knowledge building including consultation and relationship building, skill developments and support, culture and environment, making it family ready and friendly, implementation, evaluation and monitoring, and, hopefully, ending up with sustainable practice change. I'm sure many of you listening to this webinar work using implementation approach, but I just needed to emphasise that.

This slide describes – there are some three areas in which the FAPMI strategy has been working to change practice – changing workforce practice on the left, changing organisational practice and enhancing service delivery. In 2012, there was a targeted evaluation of the FAPMI strategy conducted by Monash University, Professor Darryl Maybery and Associate Professor Andrea Reupert. The themes from this evaluation suggest that the practice change was occurring across these three dimensions. Pivotal to the uptake of these change of practices is the presence of the FAPMI coordinators and other roles within the organisations – well, we call them champions sometimes. Changing the practice of workers, the left hand column, includes formal training, which has included using online resources that COPMI have provided, individual support, secondary consultations, placements, cross-placements, reciprocal placements, coaching and mentoring of individual practitioners and support.

There's been a lot of work around providing tools. One example I'll talk about in a minute has been in one area of developing prompts on lanyards that individual workers can actually wear and refer to when they are with clients and families. Changing the practice of organisations includes reviewing policies and procedures, and making sure that FAPMI issues are constantly included and referred to, partnership agreements that have FAPMI on the agenda, practice guidelines and assessment procedures. In networks, there's been a lot of work undertaken across FAPMI areas and FAPMI catchments to broaden the scope of networks to more routinely include FAPMI issues, FAPMI conversations and bring it into the space rather than just talking about families broadly. Documentation is constantly reviewed to make sure that wherever possible parents and children are identified, not just ages and gender of children, but also trying to get a snapshot of how children and families are travelling.

The right-hand column is enhancing service delivery, and that has been possible through the FAPMI initiative through brokerage funding and coordination. I'll talk about some examples of that in the next few slides. So this slide just gives a few more examples of how we believe that workers have been changing their practice. It gives an example of the "Keeping families and children in mind" support and implementation, which is an e-resource that COPMI has developed and that was a supported implementation using FAPMI coordinators and practice champions to deliver this across a number of different adult mental health sites. The "keeping in touch with your children" is an in-patient initiative that's been done in collaboration with a number of different services. It encourages parents to actually keep in touch with children when they're an in-patient and training staff to have conversations with parents about their children when they're in hospital.

We've also had joint training calendars where FAPMI coordinators have worked collaboratively with family services, with child protection and mental health community support services to share and work together on training, which has been extremely helpful. Some examples of change in the practice of organisations, I'll just go through a couple of these. I've mentioned the policy for children visiting in-patient units. The really exciting one has been the inclusion of core components of working with families, parents and children into the mandatory and essential skills training calendars of mental health services. So that, along with the other components around – risk and assessment perhaps, fire drills. Many mental health services now in Victoria have core components to equip staff and to understand what parents might be presenting with, to what questions to ask and how to support parents and children in adult mental health services.

There have also been a number of audits undertaken across mental health to collect numbers of parents and children. Audits in themselves are a very powerful tool to raise awareness when you're asking mental health practitioners, "How many parents do you have?" and, "How many children, what ages, where are they living?" It immediately raises awareness and invites practitioners to reflect on their work. The last part of the – that last column on the right – is enhancing service delivery and this is a direct service component of the strategy. That's been made possible through collaborations through partnerships and some brokerage funding. So I'll just mention a couple of these briefly.

The "Supporting kids in primary school" is an early intervention program for providing information to children and teachers in primary schools. And the Aboriginal FAPMI project is another initiative in the south-western part of the state in the Warrnambool area to improve resources and service to support south-west Aboriginal parents and children in families where parents have a mental illness. There's a range of different programs that have come about as part of the FAPMI initiative. I'm just going to talk a little bit about – the second component of my talk is – "Let's talk about children", which is an Australian first recovery model for parents.

It's a brief two or three session recovery-oriented intervention developed in Finland and the potential of this model to equip practitioners to more routinely identify parents and children early is significant. Not least because it doesn't require children to be physically in the room but also that it allows adult focused workers to elicit information about children in working with parents. It's an evidence-based program, which suggests that even a brief intervention can improve outcomes for both parents and for children. These are the – hints at a large number of people involved in this mental illness research fund project, which is funded by the Victorian Government. It's a four-year project and we're about halfway through. This study aims to adapt "let's talk" for Victorian adult and mental health services and other sectors in mental health, develop an evidence base for the model for each sector, see if we can roll it out on a larger scale and see if it has economic value. So it's got very large aims, but it's very, very promising in how it's progressing.

The next slide really tries to summarise, and it depicts the parallel processes, what we're finding out about from our work so far over the last two years, and before that about the benefits of "let's talk". It seems that – and this slide I attribute to Mel Goodyear – it depicts the parallel processes of change occurring as a result of "let's talk" for both the parent client on the right and the practitioner on the left. We think that this occurs because the parent is empowered around their parenting role. This model places the parent as expert in their children's lives and the model significantly strengthens the rapport between the parent and the worker. So we are very excited about the potential for this model.

We're also talking about the capacity to trial it in different sectors, and working collaboratively with COPMI and other parts of Australia and the world to perhaps adapting it, such as in prisons, in family violence services and even rehabilitation services. To say that we're excited about "let's talk" would be an understatement and I'm sure that Brad will talk about opportunities for people to be involved in further work in this area. The last slide really is to bring to people's attention that here in Victoria we have been developing some FAPMI practice standards and these have been very recently published in the International Journal of Mental Health Nursing.

They were developed in response to questions from clinicians in adult mental health about how do we do best practice, and questions from managers about how can we measure and monitor good practice in relation to this population. The challenge will be to progress these standards –are five stages for monitoring and evaluating care – into core practice in adult mental health and beyond. We are developing conversations with a range of people including the government about how it can be progressed, and working collaboration with people with lived experience, practitioners and managers to get these standards implemented across Victoria. So I'm going to hand back to Brad now to go back to "let's talk about children" and the national COPMI initiative.

MORGAN

I was just going to briefly highlight that the COPMI national initiative has been working for the last two to three years on developing a range of materials to support implementation of "let's talk" across Australia. This includes a freely available e-learning resource, a manual or guide to assist professionals to put the intervention into practice and there are also some resources available for both parents and young people that go along with the intervention. At the moment, we're currently piloting a set of resources that assist organisations to recognise where they are on a continuum of readiness on those layers that I discussed earlier, and then providing them with a scaffold of resources that have been developed over the last 15 years that they can use to improve and increase a readiness to be able to deliver programs such as "let's talk about children".

The other exciting thing that Rose mentioned is a capacity for this resource. Obviously we've had a strong focus on adapting it for adult mental health services at the moment, but it has a strong capacity to be used both in a number of adult services and also in child focused services, particularly organisations or programs such as early child education and care and primary schools and secondary schools, as well as family services. Just so that you know, there's a whole range of resources including most of the ones we've talked about today available for free on the COPMI website. There is a culture of sharing collaboration in this area so organisations can go to the website and download and use things in their practice.

WEBINAR CONCLUDED

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The Commonwealth of Australia, represented by the Australian Institute of Family Studies (AIFS), is not responsible for, and makes no representations in relation to, the accuracy of this transcript. AIFS does not accept any liability to any person for the content (or the use of such content) included in the transcript. The transcript may include or summarise views, standards or recommendations of third parties. The inclusion of such material is not an endorsement by AIFS of that material; nor does it indicate a commitment by AIFS to any particular course of action.

Slide outline: “Flying over the radar”: Changing practice to support children and families where a parent has a mental illness

Slide outline

  1. 'Flying over the radar' Changing practice to support children and families where a parent has a mental illness
    • Rose Cuff and Brad Morgan
    • Please note: The views expressed in this webinar are those of the presenters, and do not necessarily reflect those of the Australian Institute of Family Studies or the Australian Government
  2. Acknowledgements
    • Australian Infant, Child, Adolescent and Family Mental Health Association
    • The Children of Parents with a Mental Illness (COPMI) national initiative is funded by the Australian Government
    • Family members with lived experience
  3. Families and mental illness
    • Children of parents with a mental illness:
      • 23% of Australian children under 18
        • Maybery, D. J., Reupert, A. E., Patrick, K., Goodyear, M., & Crase, L. (2009). Prevalence of parental mental illnessin Australian families. Psychiatric Bulletin, 33, 22-26.)
      • More likely to experience social, emotional, developmental and educational difficulties
      • Higher risk of experiencing mental illness themselves
  4. Families and mental illness
    • High variation in experiences associated with:
      • Diagnosis, symptoms, treatments and recovery
      • Co-occurring health problems
      • Social and financial situation
      • Support networks and community participation
      • Trauma/intergenerational trauma
    • Other vulnerabilities:
      • Drug and alcohol
      • Family violence
      • Homelessness
  5. Families and mental illness
    • Protective processes:
      • Parenting and the parent-child relationship
      • Communication, understanding and problem solving
      • Active involvement in the community
      • Supportive network of relationships (within and outside of the family)
      • Help-seeking
      • Hope
  6. Evidence
    • Interventions to prevent mental disorders and psychological symptoms in the offspring of parents with mental disorders appear to be effective.
      • Siegenthaler, E., Munder, T., & Egger, M. (2012). Effect of preventive interventions in Mentally Ill parents on the Mental health of the offspring: Systemic review and Meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry 51(1), 8-17.
  7. Invisible children
    • These children are invisible to the mental health system and their needs are being ignored
      • Cowling VR, McGorry PD, Hay DA., Children of parents with psychotic disorders. Medical Journal of Australia 1995; 163p. 119-120
    • Very little is known about what happens to the children of mentally ill parents and their needs are largely ignored. Young people who do not receive appropriate support may be adversely affected for the rest of their lives.
      • Report of the National Enquiry into the Human Rights of People with Mental Illness
  8. Flying under to flying over the radar
    • Diagram: Flowchart of Community supports and services: System, Organistion, Supervisor, Worker, Parent, Child
  9. Lived experience partnerships
  10. National partnerships
    • COPMI national initiative and the FaPMI (Families where a Parent has a Mental Illness) initiative
  11. The work in Victoria
    • FaPMI Service Development Strategy
    • Large scale trial of a brief intervention 'Let’s Talk About Children'
    • FaPMI Practice Standards
    • Diagram: Mental Health Act, FaPMI Strategy, Victoria's Vulnerable Children Strategy
  12. A new Mental Health Act for Victoria 2014
    • Principles enshrined in the Act include:
      • Children, young persons and other dependents of persons receiving mental health services should have their needs, wellbeing and safety recognised and protected
      • Carers (including children) for persons receiving mental health services should be involved in decisions about assessment, treatment and recovery, whenever this is possible
      • Carers (including children) for persons receiving mental health services should have their role recognised, respected and supported
  13. FaPMI strategy
    • Acknowledgements
      • The FaPMI Coordinators
      • The Bouverie Centre, Victoria’s Family Institute
      • Department of Health and Human Services (DHHS) Victoria, Division of Mental Health, Wellbeing and Ageing
      • Dr. Melinda Goodyear
  14. FaPMI Strategy
    • Aims to reduce the impact of parental mental illness on all family members, especially dependent children by:
      • Capacity building
      • Systemic and sustainable change
      • Located within adult mental health services
      • Partnership building
  15. Strategy objectives
    • Increase capacity of specialist mental health services and mental health community support services to provide a family focused response to FaPMI
    • Increase capacity of specialist mental health services’ network partners to recognise and respond to FaPMI
    • Establish/strengthen capacity of networks and support structures
  16. Broadening the lens beyond mental illness …
    • Collaborations with family violence, homelessness, child and family, criminal justice, alcohol and drug treatment services sectors
    • Adopting a Child Aware approach to respond to and support vulnerable children and families
    • Linking with Victoria’s 'Vulnerable Children - Our Shared Responsibility Strategy 2013-2022'
  17. Practice change
    • Adult mental health service worker practice + Adult mental health service organisational practice = Enhanced service delivery for families
  18. Change agents = implementation
    • Establishing readiness
    • Knowledge building
    • Skill development
    • Culture and environment
    • Implementation and evaluation
    • Sustainable practice change
  19. Implementation
    • Changing workforce practice: Formal training, Tools, Individual support
    • Changing organisational practice: Policy and procedures, Documentation, Networks
    • Enhancing service delivery: Peer programs, Better access
  20. Changing workers’ practice
    • ‘Keeping Families and Children in Mind’ supported implementation
    • ‘Lets Talk About Children’ implementation
    • ‘Keeping in Touch with Your Children’ inpatient menu
    • Family, children and carer specialist positions
    • Joint training calendars
    • FaPMI ‘prompts’ (e.g. lanyards)
  21. Changing the practice of organisations
    • ‘Care of Children’ form completed at intake
    • Policy for children visiting inpatient units
    • Mandatory and essential skills training
    • Inclusion of family services into mental heath orientation
    • Intake and assessment documentation
    • Audits to collect numbers of parents and children
  22. Enhancing service delivery
    • Delivery of PATS and CHAMPS peer support groups
    • Circle of Security
    • Brokerage funds
    • Supporting Kids in Primary Schools
    • Aboriginal FaPMI project
    • Supported playgroups
  23. Let’s Talk About Children
    • Developing an Australian-first recovery model for parents in Victorian mental health and family services
    • ‘Let’s Talk’ is a brief 2-3 session recovery oriented intervention for parents with a mental illness and their children
    • Developed in Finland by psychiatrist Tytti Solantaus and her team
    • The model is a collaborative process that assists the practitioner and the parent to explore the needs of the child, the impact of mental health, and the supports they may need in their parenting role
  24. Mental Illness Research Fund (MIRF)
    • Four year project
    • Project partners: Sane Australia, Eastern Health, The Bouverie Centre, Beyond Blue, NorthWestern Mental Health, Family Life, Monash University, Parenting Research Centre, Neami National, State Government Victoria Department of Health, Children of Parents with a Mental Illness (COPMI)
  25. Four year recovery model study
    • Aims to:
      • Adapt Let’s Talk for Victorian adult mental health, mental health community support and family sectors
      • Develop an evidence base for the model for each sector (e.g. positive parent and child outcomes)
      • Determine how to implement on a larger scale
      • Determine the economic value and cost-effectiveness of a larger roll out (longer term) of the parent recovery model by Victorian and Australian governments
  26. Let’s Talk About Children
  27.   Worker Parent
    Awareness raising

    Client as parent

    The needs of the child

    The role of parent

    Impact of mental illness on family

    Strengthening confidence Conversations about parenting

    Normalising parenting stress

    Parenting self-agency

    Reflective action

    Resourcing the parent

    Referrals

    Supporting conversation

    Active, positive parenting

    Assertive, limit setting

  28. Let’s Talk in different sectors
    • Trialling in:
      • Clinical adult mental health
      • Specialist mental health services
      • Alcohol and drug services
      • Gambling services
      • Family services
    • Potential for use in a range of other settings (e.g. prisons, housing services ..)
  29. FAPMI Practice Standards
    • Essential and recommended
    • Five stages – screening through to monitoring and evaluating care
    • Aim to provide practical and realistic expectations of the adult mental health service workforce that enable services to better adapt practice to respond to FaPMI
    • Published 2015 in the International Journal of Mental Health Nursing
  30. Let’s talk in Australia
    • COPMI national initiative
  31. Resources available
    • Family information and resources
    • Professional resources, training and education
    • Organisational/implementation guidance and resources
    • www.copmi.net.au
  32. Contact details
    • r.cuff@latrobe.edu.au
    • morganb@copmi.net.au
    • http://www.bouverie.org.au/support-for-services/fapmi
    • http://www.copmi.net.au/

This webinar was held on 26 February 2015.

Australia is a leader in the field of bringing about broad systemic change in practice to improve outcomes for children and families where a parent has a mental illness. This population of children and families used to “fly under the radar” of services, particularly adult mental health services.

This webinar, presented by Rose Cuff and Brad Morgan, described the significant shift in thought leadership, policy and practice that has occurred to change service delivery and to promote systemic child and family inclusive approaches.

The webinar provided participants with an overview of the work undertaken at a national level to implement practice change and develop a wide range of resources for the workforce and families. The linkages between child outcomes and parent recovery were highlighted, and evidence-based models for parents and families to support these vital relationships were provided.

Examples of changing practice within Victoria was also be presented, including useful models for supporting parent-child relationships in the context of parental mental illness.

This webinar was presented as part of our Focus on... Supporting families where a parent has a mental illness. 

Feature image: Priceless by Lotus Carroll, CC BY-NC-SA 2.0.

About the presenters

Rose Cuff

Rose Cuff is an occupational therapist who has worked in child, adolescent and adult mental health services since 1986. Since 1995, she has focussed specifically on the area of supporting families where a parent has a mental illness through direct clinical practice, creating and implementing peer support and group programs, developing resources and conducting training and research. Since 2007 Rose has worked as the Statewide Coordinator for the Families where a Parent has a Mental Illness (FaPMI) strategy, based at the Bouverie Centre in Melbourne. The FaPMI strategy is a Victorian government-funded initiative aimed at building capacity in services to promote better outcomes for these families.

Brad Morgan

Brad Morgan is Director of the Children of Parents with a Mental Illness (COPMI) national initiative.

Comments

So great that whole families are being recognised and assisted with the impact of mental illness.
Kirsten
Thank you and I enjoyed listening. I particularly related to the 'Flying over the Radar session' and the aim of improving the "system" for families and children. Working in community mental health I have found some work environments receptive to family sensitive language, practice, training and policy and others not. I believe the differences are in the way clinical supervisors (as in the slide) behave and encourage workers to apply FaPMI and Copmi interventions. I believe clinical supervisors should be mandatorily trained (and all staff) in best practice and be required to reach bench marks or somehow be more accountable in how staff respond to kids and family needs. I see every day the influence one person can have on 'family sensitive culture" in a clinical setting, and if that one clinical leader is unaccountable, not interested in kids and carers, then the staff under them do the same despite training and policy being available. Many thanks Kath
Kath O'Sullivan
What is encouraging in this area is that focussed change in practices that focus on resilience and recovery can do a lot to make a difference to outcomes for both parents and children.
Hanna
An hour so well spent for me, thank you so much to the presenters and organisers. Will go back and listen again - the session really delivered on its promise to discuss systemic change! Inspiring for me, for one.
Darien
Thanks for joining us for the webinar last week. I would welcome the opportunity to respond to questions about the Children of Parents with a Mental Illness (COPMI) national initiative and to link you with some of the information and resources available.
Brad Morgan