Placing family at the centre of mental health recovery

Placing family at the centre of mental health recovery

Rhys Price-Robertson, Angela Obradovic and Gemma Olsen
11 August 2016

This webinar outlined ways in which practitioners can support healing and recovery in families affected by parental mental illness.

Placing family at the centre of mental health recovery

Audio transcript: Placing family at the centre of mental health recovery

Audio transcript (edited)

HIGGINS

Good afternoon everyone, and welcome to today's webinar, Placing Family at the Centre of Mental Health Recovery.  My name is Daryl Higgins, and I'm a deputy director here at the Australian Institute of Family Studies.  Today we will learn about how practitioners can support healing and recovery in families affected by parental mental illness.  Drawing on research, practice, wisdom, and lived experience, today's speakers will encourage professionals to consider how they can place family relationships and parenting at the centre of their efforts to support mental health recovery. This webinar and the related practitioner resources are a collaboration between the Child Family Community Australia Information Exchange, here at AIFS, and the emerging minds through the Children of Parents with a Mental Illness National Initiative.  But before I introduce our speakers, I would like to acknowledge the traditional custodians of the land on which we're meeting.  Here in Melbourne, the traditional custodians are the Wurundjeri people of the Kulin nation, and I pay my respects to elders past and present, and to the elders of other communities who may be participating today from all around the country. 

I would also like to alert you to some brief house-keeping details.  One of the core functions of CFCA, the Child Family Community Australia information exchange, is to share knowledge, so I would like to invite everyone to submit questions via the chat box at any time during the webinar, and there will be some time to respond to your questions at the end.  We'd also like to continue the conversation beyond today, and so to facilitate this we've set up a forum on our website where you can discuss the ideas and issues raised, and submit additional questions, and we will send you a link to the forum at the conclusion of today's presentation.  And please remember that we're recording this webinar, and the recording and the transcript and the slides will be made available in due course.  

So now, it's my great pleasure to introduce three speakers for today's webinar.  First, Rhys Price-Robertson is a PhD candidate at Monash University, where he's investigating the experiences of families affected by paternal mental illness.  At the time of preparing this webinar, he was a knowledge broker for the CoPMI, the Children of Parents with a Mental Illness national initiative.  His most recent publications, published research is focused on fatherhood, family recovery, family relationships, and child protection.  And previously, it was a great delight to have Rhys as a staff member here, as a researcher at the Institute of Family Studies, so welcome back Rhys.  

Joining Rhys is Angela Obradovic, who's worked in the clinical adult mental health field as a mental health social worker for over 23 years, and has been involved with the CoPMI national initiative since 2002.  As chief social worker for an area of mental health servicing Victoria, Angela has led implementation of the family consultation and multiple family group models, parent and child peer support programs, and the Let's Talk about Children intervention.  And her recent research has included an evaluation of cross-sectoral approaches to the care of families where a parent has mental illness.  

And finally, Gemma.  Gemma Olsen is the mother of two, and lives here with her husband.  Her life has been touched by mental illness for as long as she can remember, and her lived experience include being a child of a parent with a mental illness, and living as a parent with a mental illness.  She also identifies as a carer, and she has at times found herself in a caring role for her loved ones.  Gemma has worked in the mental health sector, endeavouring to create lasting change for the lives of people living with the symptoms of mental illness, their carers, and thief families.  So please join me now in giving our presenters a very warm, virtual welcome.  Thank you.

PRICE-ROBERSTON

Thanks for your introduction Daryl and thank you everyone for logging in.  So as the title of this webinar indicates, today we're going to be focusing on the recovery approach in mental health, or the recovery model as it's sometimes called, and particularly we want to explore the ways in which it can be reconceived so that it's less individualistic, and so that it pays more attention to the pervasive importance of relationships in people's lives.  So in my talk, I'll provide some of the background to the idea of recovery and try to make the case for why we specifically need family-oriented models of recovery.  Angela will share some thoughts and examples from a practice perspective about how families can be supported in recovery, and finally Gemma will reflect on her professional experience as well as on her lived experiences, both as a child of a parent with a mental illness, and as a mother in recovery herself.

Okay, so you can see, you can see an outline of my talk.  First I'll briefly look at the recovery approach so that those who are less familiar with it get a better sense of what we're talking about.  I'll explore the idea that recovery tends to be underpinned by a very individualistic ethos, and then I'll give some examples of models and studies that do put relationships at the centre of recovery.

So what is the recovery approach?  There's no definitive answer to this, and people come at recovery from different angles, but I guess in the most basic sense, recovery offers an alternative to what gets called the, "Medical model" of mental illness.  So in this medical model, the goal is clinical recovery, which means remission of the symptoms of mental illness.  Mental illness is treated as a biological disease, normally a faulty brain, and the aim is to get rid of the disease, often using physical means like medications.  The problem is that, for many people with enduring conditions like Schizophrenia or bipolar disorder, complete clinical recovery – at least in the short- or medium-term – is variable.  So the medical model offers this binary: you're either sick or you're healthy.  But starting in the US in the 1960s and 70s, more and more people started questioning this binary, and eventually this new idea of personal recovery really took form, where it was seen as possible to live a satisfying, a hopeful, and a contributing life, even within the limitations caused by mental illness.

So the consumers who developed this approach were saying that they didn't accept the simplistic terms by which their experiences and lives had been defined, and so what started out as a radical alternative to the establishment has gradually been embraced across the English-speaking world.  It's still not totally mainstream in Australia across all mental health sectors, but in some areas, like in the non-clinical mental health centre, recovery has become the guiding approach, and I think in general, recovery has been a very important development in the field of mental health in a number of ways. But like any approach, it is imperfect and is certainly not without its critics.

Probably the most consistent criticisms focus on the individualistic world-view that underpins most views of recovery, and there's a couple of different ways we can look at individualism here.  The most common way to contrast individualism to collectivism.  So compared to more traditional cultures in Australia, we're culturally individualistic.  But we can also look at individualism in a more philosophical sense, where it's actually opposite of something like interdependence.  It's the opposite of systems or ecological views of the seeing the world.  This kind of individualism sees people in some basic way as islands unto themselves, rather than as beings who are connected to, who are dependent on, and are embedded in the world around them. And in my view, recovery is individualistic in both of these senses.  

Put simply, recovery models tend to strongly emphasise subjective meaning and personal journeys, and to de-emphasise contextual factors.  And by contextual, I basically mean anything external to the individual. So let's have a look at the classic definition of recovery from William Anthony in the early 90s, and this definition is quoted very widely, and it sees recovery as "a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles".  So you can see that recovery is construed as a deeply personal process of modifying or outgrowing limiting thoughts, feelings, and beliefs.  It's a process of personal transformation.  The onus of recovery is placed squarely on the shoulders of the individual, and there's no mention, or very little mention, of the social or structural determinants of mental health, even though they have been consistently identified as amongst the strongest predictors of mental health outcomes.

I just want to be clear that I'm in no way suggesting that it's a problem that people develop personal meaning or that people put efforts into getting better.  These are obviously important things.  The problems start when the focus is so heavily on this personal side of the equation that the models that we use end up conceptually and practically disconnecting people from the contexts in which they exist. 

Now of course, recovery has come a long way since the 90s when that definition was first given.  There are now a number of frameworks that attempt to capture the various elements that comprise personal recovery.  One of the most popular of these is the CHIME framework, so I'm going to quickly focus on that as an example.  

CHIME is the acronym for the five recover processes in the model, and you can see these on the slide.  Clearly, the C stands for Connectedness, so this framework is less obviously individualistic than the definition I showed you, but still it shares many of the characteristics of earlier views of recovery.  Recovery is characterised as "an individual and unique process", and again the social and structural determinants of mental health warrant limited mention, and with the exception of connectedness, all of the CHIME recovery processes are construed intrapersonally.  So in the very structure of this framework, connectedness sits aside the four intrapersonal recovery processes, which in my view just reinforces that that which goes on inside people's minds or inside their bodies is somehow fundamentally separated from that which goes on in their social interactions.  In this model, social life and relationships play a secondary role, and a largely instrumental one.  Their role is to promote the real work of recovery, which is ultimately a process of subjective transformation. So what would it look like for a recovery model to properly acknowledge relationships and interdependence?  

I want to give you a few examples now, but I've got limited time to do this so I'm really going to move through these very quickly.  The first example comes from the growing literature, looking at how recovery can be made more relevant for people from diverse cultural and linguistic backgrounds.  This example comes from Toronto, where service providers on the ground were indicating that the strategies associated with recovery tended to be culturally insensitive.  That they failed to address issues such as migration stress, social marginalisation and racism.  So you can see a quote from this culturally responsive model of recover here, "recovery thus refers not just to the processes of hope, healing, empowerment, and connection occurring at the individual level, but also to the need for these processes to work at other levels.  Hope encompasses not only an individual's belief that a better life is possible for himself, but a broader sense of opportunity for an entire cultural-linguistic community."  And that quote goes on, I won't read the whole thing.  

So this model not only foregrounds the structural components of recovery, but it also really demonstrates a properly relational understanding where personal experiences are seen as inseparable from the social and the cultural. The next body of literature I want to touch on is the growing empirical research on the social nature of recovery.  A good example is a grounded theory study in Sweden, where researchers attempted to determine the main factors that respondents themselves identified as being conducive to their recovery.  The core category that emerged from this analysis was recovering through a social process, so in this study achievements that are normally seen as deeply personal, such as positive changes in self-perception and identity, were actually identified as interpersonal processes.

I want you to look at the language the authors are using in the quotes up there and the bits that I've highlighted.  Social relationships didn't just shape or didn't just contribute to changes in participants' identity, rather the social was seen as where recovery takes place.  It was through social relationships that participants were able to redefine their own experiences.  In other words, the social world was the very medium through which personal transformation became possible.  In my reading, this has a very different feel to a model in which connectedness is just one among a number of separate components.  

Finally, and most relevant to today's webinar, is the growing literature on family recovery.  I put this quote up here because I think it demonstrates the richness of this literature.  Here, Joanne Nicholson from the US is talking about a model she developed for mothers with mental illness, and she says, "Clearly, women who are mothers are not living in a vacuum.  The context of their lives is often defined by family parameters.  Families are commonly understood as systems in which members are engaged in reciprocal relationships and events are multiply determined by forces operating within and external to the family."  I think it should be clear how different this conceptualisation of recovery is from the definition I read out initially.  

By way of summing up, I just want to leave you with a few reflections, and maybe they can kind of frame the next couple of presentations.  First, acknowledging interdependence in the way that I have been describing doesn't mean that all of our interventions will be about increasing people's collective experience.  For some people, moving into a sense of empowerment, for example, might entail extricating themselves from certain relationships, or even from their families.  But the argument I've been making is that even this would have to be seen as an interpersonal act, ultimately an expression of interdependence.

I honestly have no idea what empowerment would even mean in a relational vacuum.  Second, families are really important to a lot of people living with mental illness; we could talk about connectedness and interdependence in a kind of abstract way like I've been doing, but for many people we also need to get specific and look at how their families and how their children if they have them are related to their recovery and finally I hope I've said enough to convince some of you that putting families at the centre of recovery involves more than just adding some family friendly wording to a pre-existing individualistic model.

I believe it really challenges us to think carefully about the basic nature of mental health and recovery.  Okay so that's it from me, I know it's been quick but I hope that what I've been saying has made some sense to you and perhaps even challenged your ideas a little bit.  Now I'll hand over to Angela who's going to further explore some of these ideas at a practice level.

OBRADOVIC

Thanks Rhys.  Good afternoon and welcome everyone.  It's really very heartening to see how many people have expressed an interest in the topic we're looking at today and certainly hope we can build on the practitioner resource that was released last Friday.  I wanted to start by recognising and thanking the significant group of people with lived experience and the practitioners who work with them; for the essential contributions and collaborations they've made to this area of mental health over the last 15 to 20 years. I'm aiming to spend a little time talking about the importance of language and of lens, given the diversity of our practice settings and then touch briefly on the evidence base that exists for family interventions in relation to mental health, highlighting some of the barriers and the constraints to engage in families where a parent has a mental illness and the impact these have on recovery and wellbeing.  I'll end by introducing you to a few examples of tools and models that have proven helpful in overcoming those barriers and in promoting open conversations about parent and family recovery, regardless of what sector we work in.

I wanted to begin by acknowledging that the majority of you will be working across a range of sectors we assume are primarily centred on children, parents and families in the main, but also from public and private mental health.  What I believe that means is that we are sharing complementary expertise about working with families, vulnerabilities, complexity and often in a system where our preventative desire and intent is nevertheless seated in a risk and problem saturated environment and often with some aspect of a statutory responsibility.

While we have much in common in our service context, it can also restrict the lens through which we see things and that includes the family.  I often ask colleagues in my service when they're talking about family sensitive practice, which family are you talking about?  There is a need to do that because historically within an adult mental health frame, family has largely been seen as another person, usually a carer because the relatives of consumers engaging with mental health services come from families of origin; that is the adult parents of our adult consumers.

Within a child and parent focused agency of course, the family constellation that initially comes to mind is the family of procreation or choice, where the primary focus is on the parent-child relationship.  We can see family through these two different lenses; in relation to parents with a mental illness and family recovery, the challenge is to use both lenses, the adult as a parent and a partner, as a member of their families and not to regard the family as the other.

While it may seem very self-evident that family encompasses both constellation types, it's amazing how easy it is for one or other to become invisible or dominate.  While many of the contemporary practice approaches that are flicking on the screen may be familiar to all of us, they too often have an emphasis on one type of family constellation and even the language of trauma informed and culturally sensitive strengths based models can be contextually skewed.

As you can see from this summary slide, there has been significant evidence available for quite a while illustrating the improvements in wellbeing, health and family functioning for all family members when mental illness is impacting.  The same exists in relation to children in families where a parent has a mental illness.  A whopping 40 per cent decrease in intergenerational mental illness and we're talking here about gold standard randomised controlled trials.

Nevertheless, research often doesn't get translated into practice and there are reasons for that.  Apart from the constraint of language and lens, what else gets in the road of family recovery?  Factors that hinder family engagement and recovery can be described at each of the different system levels, from the intrapersonal right through to societal levels.
As you look at the aspects on this slide impacting at an intra and interpersonal level, I'm sure that most of them will not be unfamiliar to you, because they're generally the features that operate within vulnerable and disenfranchised communities.

For a person with a lived experience of mental illness, the effect that stigma in particular has on self-concept and identity, on the ability to engage and feel safe connecting with others, in belonging and acceptance including self-rejection and self-stigmatisation, is doubly amplified when the person's a parent.
Keeping with the theme of multiple lenses, the issues displayed on this slide resonate not just for the parent, but with each member of their family, in their different roles and also for any one member of the family in their multiple roles.

Many parents with a mental illness are children of parents with a mental illness and their own intergenerational experience that can also feature trauma, contributes to compounded feelings often of shame and guilt, transmit a lack of trust and hope and witnessing of judgment and blame over generations, most of which has the potential to interfere with the critical ingredient of help seeking in times of crises and adversity.  Not only is one individual's experience of illness and its consequences highly likely to impact their intimate and familial relationships, for instance symptoms that reduce people’s capacity for engaging in equal balancing relationships, but also the capacity and motivation for this is informed by and influenced by those around them who are similarly affected.

There are some quotes from people with lived experience in this situation on the slide that I think it illustrates the depth of reluctance, ambivalence and fear that exists when we try to invite discussion about family and mental illness.  One of our parent peer workers once shared with other parents the analogy her father gave her of the sequence needed to save lives when the emergency oxygen mask drops in a plane.  Parents are instructed to put on the mask first specifically, because it's counter-intuitive to a parent's instinct.  She talked about how important that permission giving was from him to her to assist her in shedding guilt and prioritising the recovery that later allowed her to resume her son's care.

A woman who was a carer, peer educator and advocate, a mother and a carer of her daughter who was a mum with a mental illness once said to us, "Despite all I know about mental illness and its likely causes, I still can't shake the belief buried deep in the marrow of my bones that somehow I caused this or contributed to it.  It's irrational but there it is."  And to illustrate the point that judgment is witnessed and absorbed by children, one of our young carers overhearing a comment from someone in a workshop when a group were developing a vision statement for work to do with children of parents with a mental illness and wanted to look at a – creating a better life for them, she responded emphatically with "I don't need a better life, just support to live it.  I love my Mum regardless of how hard this might look to you."

In fact, past experiences of attempting to disclose or share concerns about these issues with families and friends or with professionals, are one of the first things people cite as underpinning their reluctance to open up.  They're more often than not cautious and without confidence that they'll be heard and supported.  The therapeutic power of speaking and being heard, of coming to regain trust and hope is often cited as the element that tips people into taking risks to alter patterns, hence the importance of reflecting on our own values and assumptions about mental illness, families and parenting is important before we approach that conversation.

Despite these constraints, we know from lots of arenas that engaging individual family members and the family as a whole is possible, is welcome and is enabling.  The practitioner's resource that's just been published outlines a set of six strategy areas for promoting family recovery and poses some questions for reflection, either for yourself or potentially within a staff group session or in an organisational review that might be useful.  I'm going to provide a few examples of practice that attend to the constraints that often prevent families and practitioners from engaging in dialogue and collaboration together and I'm only going to be looking at two of those areas because we don't have much time today.

One of the areas is focusing on strengthening parent and child relationships and while again, that might seem like a self-evident area of practice, it bears repeating that encouraging reflective action, normalising the need for support for all parents and avoiding assumptions about the way illness impacts in a particular family is important and one of the most potent antidotes is the narrative of other parents in the same situation and the hope-inducing that comes from practitioners who continue to offer choice even within limitations that might exist. One of the specific examples I wanted to introduce you to is a thing called the Keeping In Touch With Your Children menu, that was devised specifically for acute adult psychiatric inpatient units.  We know that an inpatient admission is a time of crisis and very mixed emotions that can significantly impact on people's wellbeing.  Parents are often overwhelmed by feelings of guilt and fear particularly at this time and when anxieties like this are unattended to, they actually interfere with the recovery of that individual experiencing mental illness. Children also without having that anxiety attended to internalise and can act out their distress and confusion.  So whilst we can't easily prevent separation when somebody's acutely unwell, we can act to minimise the trauma associated with it and this particular menu organises itself around a staged process of maintaining connections, about assuming that the conversation about parents and children visiting them in hospital is an active and normal part of a conversation that occurs during this time.  This menu offers different options for people, depending on their level of wellness and readiness to stay connected in whatever way they can and it's also an incredibly important reminder for staff, the places that it exists, particularly in my inpatient unit is that it's framed on the wall in a number of places; it's not just a poster, it's there as a reminder of the position that that unit takes on keeping this as part of the recovery process and valuing it.

Another very important intervention that you might have heard about is Let's Talk about Children.  It's a particular intervention that focuses on developing conversations in a collaborative way between practitioners and parents about their children without increasing guilt.  It's a process that uses a developmental log to explore the needs of the child, the impact of mental health on those children in families and the supports they might need in their parenting role.  It ultimately empowers parents to make changes in their family and it often leads to also considering how children understand their parent's mental illness and how parents may approach a conversation with their children about mental illness. This is a model that's been trialled in Australia, originated in Finland and it is being trialled in Victoria in particular across mental health sectors and the Child and Family Service Sector.  It involves a very particular practice stance and is very much supported by practice development for staff so that this parallel process of reflection, of awareness raising, of strengthening confidence and taking reflective action occurs together in both the realm of the parent and the worker and the encouraging results from the research that's currently being undertaken, is a reduction in parenting stress, an increase in parenting self-agency, an improvement in quality of relationships and particularly in the therapeutic alliance and paralleling the improvements in people's recovery; revealing the thing that we've always suspected, there is a link between parenting and recovery. The other thing that I wanted to alert you to is that Australia has world class resources to enable conversations with parents, children and young people that are written by Australian authors and embody key messages that parents and other family members, children and young people need to hear to validate, normalise their experience and to reduce isolation, shame, negative self-image and disempowerment that blocks change and recovery.  You can see from these, some of them might be familiar to you, they're among school reading lists but they are exceptional from the children's picture book end of the world, right through to teenage fiction.

As well as that, there are a number of resources that the National Initiative produces to assist practitioners to talk to families about how they might talk within their families, discussions with children and also even within early childhood and education sectors, to promote a better understanding in mental health literacy that enables us to be able to have more open conversations. The common element to all these examples, the literature and booklets is of taking a more sensitive approach to opening up the discussion.  About creating a safe space to explore the ambivalence and fears that family members might have of normalising those conversations so that we circuit-break the silence and the myth making that reduces people's hope and motivation to take action in their life.  And to disrupt the very powerful part of illness that thwarts connection. I might leave you with those resources because at a simple level it's an opportunity here perhaps to ask within your own services, if they're not available, how you might look to introduce them and perhaps use them as a vehicle to consider any other professional development that you're staff group would be interested in looking at, so that they could use these resources with some level of confidence.  And I think I might now hand over to Gemma who's going to talk to you from a lived experience perspective.

OLSEN

Thanks Angela.  Hi everyone, I'm Gemma and today I'm going to be talking briefly about my family's journey with mental illness.  Family, identity and recovery and what it means to me.  And what were some of the keys to our recovery.  So first I'll share some of my family's journey.  Before I begin I would like to acknowledge my peer's families affected by parent and mental illness both past and present.  So I'm a mother of two children aged 13 and 5 and I'm married to a wonderful man, Andrew.  I've working in the mental health sector in both public and community arenas, as a lived experience practitioner for quite a while now.  In roles including carer, consultant, consumer and care participation co-ordinator, achiever and carer peer support work and carer consumer family and child of a parent with a mental illness representative. I was brought to this work by my lived experience and the recovery of my family which has been a long journey.  My family of origin includes my dad, mum and two younger siblings.  

Mum and Dad tried really hard to give us a happy life, but life got in the way.  Mum and Dad lost a baby when I was six years old and things were never the same afterwards.  My Mum became grief stricken and deeply depressed and her childhood traumas started coming back with a vengeance.  And my Dad also started showing signs of what we now know to be psychotic symptoms. These lasted for years.  Dad could no longer work and as a Daddy's girl having the man who used to take me bushwalking and watch documentaries and Star Trek with me, start to yell at me and tell me that aliens were coming but not to be afraid was very scary and isolating.  

When Dad finally did receive help in the late 1990's after several years and much begging from Mum, that brought its own traumas.  Such as Dad being taken away by police to the hospital several times, without us knowing what was happening.  Dad turning up at the door when we thought he was still in hospital.  Going to visit Dad and being followed around the ward and Dad nearly burning down a building and himself after he was put in accommodation without our knowledge. As a child of a father who lives with the symptoms of Schizoaffective disorder, I was by experience an almost complete lack of support for families affected by parents with mental illness.  The fact that the person suffering from acute state of illness was a parent and had a family at home was not taken into account.  My mother, my two younger siblings and I were left in the dark about what was happening to our dad, and we needed to know what was happening to Dad.  Was he okay?  Would he ever get better?  And what help was there for us kids and Mum to recover.  

Mum was left to look after children seriously affected by what we had seen happening and what had happened to our family in the process. We were living in poverty as Dad could no longer work and neither could Mum.  We stopped going to school, I think that we attended about 20 percent of school for years and years and years.  We had no mode of transport as my parents had to sell the car to get by.  DHS were involved and I was thrown into the role of carer whenever my Mum was burnt out.  Our family being kept in the dark and our needs as a family and my Dad's as a father not being recognised, had a detrimental effect that I feel is still being felt 20 years later on the mental and physical health and life opportunities of my two younger siblings, my mother and my father and myself. The only ray of hope was a program called CHAPPS, which later became a program supported by the Family Initiative, which our own child has attended.  

At 12 meeting other children like me and realising I wasn't alone made a difference.  It's a peer support program where I got to meet other kids who were experiencing similar things.  I ended up leaving home at 15 and not long after became a parent myself.  And I struggled very hard to create a happy and safe and fulfilling life for my daughter and myself.  When I was 21 and had just started my dream university degree I entered the most profoundly devastating period of depression I've ever experienced following another great trauma. Now I was the parent who had difficulty accessing services and my daughter was the child in the dark.  For years I had worked towards recovery from my childhood experiences.  Now with cruel irony my depression had begun to affect my daughter and I found myself caring for her as she started experiencing the low moods, anger and anxiety that had been the hallmark of my childhood.  I ceased my university course and tried and tried to hang on.  During this time I met and fell in love with my beautiful husband who was to experience a crash course in mental health and who has walked alongside my daughter and I on our road to recovery.

In 2010 we decided to add a new member to our family.  My pregnancy exacerbated my symptoms and not long after my son was born we moved to the other side of Melbourne to be close to Andrew's very supportive family.  Our move meant that my mental health treatment was transferred to a clinical adult mental health service which was parent child and family focused.  My husband began attending psychiatric appointments and we felt welcome and my family participated in a number of programs and our real healing began.  I joined (indistinct) play groups specifically ran for parents with a mental illness and their young children.  And I cannot exaggerate the positive impact it had on the recovery and well being of my family.  This was a safe space in which I could just be myself and we could just be mother and son. My participation normalised my experience at being a parent with a mental illness and supported me as an individual too.  It was a place where no matter what kind of week I'd had, I could turn up, have a coffee, play with my son, have a chat with the facilitator including a peer support worker and work out feeling like I'd done something worthwhile for the week.  

My daughter then attended the CHAMPS program and although I'd always been open and honest about mental health, she came home from the program bursting with knowledge, confidence and pride.  She'd been recognised for what she had done as my daughter to help her Mum through the darkness.  She'd met other kids who understood when she described what a bad day was.  And she couldn't wait to get home to teach me a thing or two. In 2012 I was a participant in a new program supported by FaPMI and the national COPMI Initiative.  It's called "Let's Talk About Children".  It's a strengths based intervention where I was once again empowered and acknowledged as a parent. My children's wellbeing was taken into account and I was helped to feel that I was enough.  The program taught me skills I needed to engage in conversations with my family concerning my mental health and our future.  But most importantly it gave me validation as a parent not just a woman suffering from depression.

My family's involvement in programs which gave us access to peer support, spaces where we could be ourselves, a way to learn about what was happening to us, took into account our real lives and gave us hope for the future, have, I believe, the key early interventions that may cease the intergenerational mental health symptoms in future generations of my family.  Through a focus on relational recovery, not just personal (indistinct) and clinical recovery, these programs have given us the tools and support to understand our experiences.  And allowed us the space and resources we all needed to recover. So the next slid is just looking at family identity and recovery.  What I wanted to highlight is that in my story, I wanted to make it clear that my recovery and that of my family hasn't been in isolation.  It was done with all of us and it didn't really happen until everyone was taken into account and we were all seen.  I was the invisible child for a long time.  At one mental health service as an adult also as the parent, I felt that I was viewed but my kids were in the background also and I felt unheard, powerless and pretty broken.

So now in my work I make sure to ask people who matters to them, and if possible I get to know them enough to refer them on to family or individual work.   If in my position it's not my role to work with the family, there is someone out there who can.  And quite often a lot needs to change around a person or a family for life to get better.  So I found that bringing in people around them really matters.  Actually talking it through so that's where "Let's Talk" has been really, really important.  I've also found that if you can't work with someone's family or important people, sometimes giving them information to take home can help, it's another way of bringing people together. And also working with other services that are involved, with the person who you are working with, I think it can put people in the driver's seat and make them feel really empowered which is fantastic.  At different times in my life I've felt pretty typecast.  I've been the woman with depression, or I've been the child whose parent has a mental illness, so I've been the mum who's unwell.  

But now after a long journey I know I'm a mother, I'm a daughter, even when I'm not speaking to my parents or my daughter, and that's where even – that's where relationships matter no matter what's happening whether you're seeing someone. I'm a wife, I'm a friend and I'm me.  I won't be put in that box where I'm just a person who experiences low moods anymore.  My father's not just one person - you know he had people around him and he was unwell.  My Mother has other things going on and every single person I worked with even if you think that someone's very isolated, they all have someone.  And we all need to feel loved and needed. So, I want to talk about some of the keys to our recovery.  Recovery is different for every family but these are the things that have really helped mine and what I found have helped other families that I've worked with and that I know personally.  It's one thing that I find really, really important is finding out who you are as a family separate from your roles within the family.  So that's not just being a carer or a parent with a mental illness, it's being a wife, a husband, a child, a parent.  It's being able to have fun together, is a really good way to do that.  And actually being around other families. I found respite was really, really helpful for my family because we got to just go out and not talk about mental health all the time and attend appointments.  And play group was really good for that as well.  Finding out who we are as a family that has been impacted by mental illness and what that means for us, so that was framing how - what our experiences meant to us and what they'll mean in the future.  

So that has meant for us, taking it by the hand and saying this is what we've experienced and this is the impact and the meaning that we want to come out of it, and passing it on as well.  And getting quality information so that we can base what we're looking at on that quality information so that's going – that's your peer support again. Information through COPMI, I found really, really helpful and also through our practitioners that have worked with us.  Planning what to do if someone becomes unwell again has been a really important safety net for our family.  On the COPMI website there's some really fantastic family care plans.  It just can make you feel better because you know that if you do get sick that there are things taken into account.  So what's your child 's favourite toy, where's – what Medicare card.  Those things and you can talk about it as a family, 'cause I know that as a child I used to worry about those things even if they're not talked about it.  I thought about it, where I'd be if someone got really sick again.  

Knowing what help is available – you get given a lot of information when someone goes to hospital. I think it's really good to have a booklet where it's just got a lot of links and resources there, or having someone to just call.  So I thinking COPMI is really important there.  I think that having a family worker in your area is really important.  And also other parents can be really good source of information.  And I think the internet's been really helpful for finding things.  I myself didn't really know about carer supports until I'd been caring for about 15 years.  So it's really good to get in there early, with some – knowing what help's available. Acknowledging the effect the past has had on it goes back to finding out who we are, but I think that that can be a really individual thing as well.  That we come together with it, so it's really looking at okay – so even my husband, what affect has my mental health have on my husband.  And then we can talk about that.  So that's going through things like the trauma of the experience the depression, the effect on finances and our health.  

Counselling I found really helpful for our family.  Value in lessons we have learnt, the strength and the courage. My child's one of those kids at school, my eldest child and the youngest now, where people come and talk to them and ask them questions because they have inner wisdom and I think that's gorgeous.  And yeah that comes from a lot of the things that they've learnt.  The other things were empathy and understanding from services.  When I found practitioners who really, really listened to me and I felt like I could talk, being a parent with mental illness it can be really hard to open up.  There's a fear that you'll be stigmatised or that something bad could come of it.  So that's where opening the conversations in a safe way, let's talk can be really good.  Understanding that everyone has a story can be really important.  Be heard and understood, really important.  That can be a bit different, that can also be around every aspect of the service, that can be from inception intake.  

I think that carers being listened to is really important too. Having access to quality family focused programs was just amazingly important, so that's CHAMPS program, that's Let's Talk, that's COPMI resources, that's respite, that's a lot of the things that we've done which have helped us stay together and be happy.  Having fun together, I think that's just – we try and do it every day.  Services working together and making appointments on certain days.  I know that I've been – I used to say that my job was going to appointments, at certain times in my life.  And I've worked with families where that was the case too.  So one of my suggestions was to get out a piece of butcher's paper, write out the calendar and say okay, this is for this person's appointment, this is for this person's. And everyone who's working with the family get on board and actually make appointments on certain days if you can, because it frees up time for the other healing to happen.  

That's actually a really big one and people don't really think about it until it's highlighted, 'cause it can be very busy.  And yeah number one has been peer support.  It's being around other people and feeling like you're not alone.  Feeling like you're good enough, that really came from peer support for me. Okay, so I think that – thank you for your time and I think we're going to go – oh yep they're my conclusions.  There are many stories of family recovery, ours is just one.  As I said talk to the families that you're working with because they've got amazing stories and every one's different.  The strength, love and care that I come across when working with families impacted by mental health never ceases to amaze me.  I wish you all the best with your work.

WEBINAR CONCLUDED

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Slide outline: Placing family at the centre of mental health recovery

Slide outline

  1. Placing family at the centre of mental health recovery

    • Rhys Price-Robertson, Angela Obradovic and Gemma Olsen
      • Children of Parents with a Mental Illness (COPMI)
      • Child Family Community Australia, Australian Institute of Family Studies, Australian Government
      • Emerging Minds: Advancing the mental health of infants, children and adolescents
    • The views expressed in this webinar are those of the presenters and not necessarily those of AIFS or the Australian Government.
  2. Beyond individualism in mental health recovery - Rhys Price-Robertson
    • Outline the recovery approach
    • Explore the idea that the recovery approach is underpinned by an individualistic worldview
    • Briefly introduce relationally-oriented conceptualisations of recovery
    • Reflections
  3. The recovery approach
    • Origins in the psychiatric survivor movement of the ‘60s and ‘70s
    • Developed by mental health consumers
    • An alternative to the medical model of mental illness
      • Clinical recovery: remission of symptoms
      • Personal recovery: "living a satisfying, hopeful, and contributing life even within the limitations caused by illness" (Anthony, 1993, pg. 17)
    • Recovery is a journey rather than a final destination
    • "Being in" recovery rather than "recovering from"
  4. The individualism of the recovery approach
    • Critics argue that recovery is highly individualistic (e.g., Adeponle et al., 2012; Harper & Speed, 2013)
      • Individualism vs collectivism
      • Individualism vs interdependence
    • Anthony’s (1993) seminal definition of recovery: "…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even within the limitations caused by illness." (pg. 17)
    • Very limited emphasis on social and material determinants of health
  5. The individualism of the recovery approach
    • CHIME framework (Leamy et al, 2011):
      • Connectedness
      • Hope
      • Identity
      • Meaningfulness
      • Empowerment
    • Recovery journey is still one of personal transformation, "at its heart… a subjective experience" (Slade et al., 2014, pg. 12)
    • Fails to rigorously account for the ways in which experiences like hope, empowerment, etc. are actually developed and sustained
  6. Beyond individualism in recovery
    • Growing number of culturally-sensitive approaches to recovery
    • Example: Culturally responsive model of recovery "Recovery thus refers not just to the processes of hope, healing, empowerment, and connection occurring at the individual level, but also to the need for these processes to work at other levels. Hope encompasses not only an individual’s belief that a better life is possible for himself, but a broader sense of opportunity for an entire cultural-linguistic community. Healing means not just that an individual’s distress is lessened, but that his extended family is able to move toward better health and functioning. Empowerment speaks to parents’ wish to be able to act so as to create a better life for their children, and also to the need for communities to be active participants in making decisions about the government systems with which they interact." (Jacobson & Farah, 2012, pg. 335)
  7. Beyond individualism in recovery
    • Literature on the social aspects of recovery
    • Example: Grounded theory study in Sweden (n=58) with the aim of determining the main factors that respondents themselves identified as being conducive to their recovery (Schön, Denhov & Topor, 2009)
      • The core category was "recovering through a social process, which emphasized social relationships as decisive in recovery from severe mental illness" (pg. 339)
      • "An individual’s recovery takes place within a social context and the respondents in this study attached central importance to the relationships in their lives. …It is through social relationships that the individual is able to redefine themselves as a person (as opposed to a patient)" (pg. 345)
  8. Beyond individualism in recovery
    • Models of family recovery (e.g., Maybery et al., 2015; Nicholson, 2014; Wyder & Bland, 2014)
    • Example: Nicholson’s (2014) model of family recovery "Clearly, women who are mothers are not living in a vacuum. The context of their lives is often defined by family parameters. Families are commonly understood as systems in which members are engaged in reciprocal relationships (i.e., family members affect each other) and events are multiply determined by forces operating within and external to the family. For mothers living with mental illnesses, recovery is a dynamic process that contributes to and is influenced by family life, family experiences, and the well-being and functioning of other family members." (pgs. 6-7)
  9. Reflections
    • Relationally-oriented models of recovery do not necessarily encourage an increase in collective experience. Rather, they acknowledge the inherent interdependence of human lives.
    • For many people with a mental illness, family is the most important interpersonal context.
    • Placing family at the centre of recovery involves more than simply "tacking" family on to existing recovery models.
  10. References
    • Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11-24.
    • Adeponle, A. , Whitley, R., & Kirmayer, L. (2012). Cultural contexts and constructions of recovery. In A. Rudnick (Ed.), Recovery of people with mental illness: Philosophical and related perspectives. New York: Oxford University Press.
    • Harper, D., & Speed, E. (2013). Uncovering recovery: The resistible rise of recovery and resilience. Studies in Social Justice, 6(1), 9-26.
    • Jacobson, N., & Farah, D. (2012). Recovery through the Lens of Cultural Diversity. Psychiatric rehabilitation journal, 35(4), 333-335.
    • Leamy, M., Bird, V, Le Boutillier, C., Williams, J. & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry, 199: 445-52.
    • Maybery, D. , Meadows, G. , Clark, J. , Sutton, K. , Reupert, A. , & Nicholson, J. . (2015). A personal recovery model for parents with mental health problems. In A. Reupert, D. Maybery, J. Nicholson, M. Gopfert & M. Seeman (Eds.), Parental Psychiatric Disorder: Distressed Parents and their Families (pp. 312-323). Cambridge: Cambridge University Press.
    • Nicholson, J. (2014). Supporting mothers living with mental illness in recovery. In N. Benders-Hadi & M. Barber (Eds.), Motherhood, mental illness and recovery. Switzerland: Springer International Publishing.
    • Schön, U. K., Denhov, A., & Topor, A. (2009). Social relationships as a decisive factor in recovering from severe mental illness. International Journal of Social Psychiatry, 55(4), 336-347.
    • Slade, M., Amering, M., Farkas, M., Hamilton, B., O'Hagan, M., Panther, G., . . . Whitley, R. (2014). Uses and abuses of recovery: Implementing recovery-oriented practices in mental health systems. World Psychiatry, 13(1), 12-20.
    • Wyder, M., & Bland, R. (2014). The Recovery Framework as a Way of Understanding Families' Responses to Mental Illness: Balancing Different Needs and Recovery Journeys. Australian Social Work, 67(2), 179-196.
  11. Family and Relational Recovery - Practice Perspective - Angela Obradovic
    • Outline
      • The importance of language and lens
      • The evidence for effectiveness of family focussed intervention
      • What hinders family engagement and recovery?
      • Introducing the ‘Supporting recovery in families affected by parental mental illness’
      • CFCA Practitioner Resource
      • Practice Examples
        • Focus on strengthening parent–child relationships
        • Assist family members to better understand, and communicate about, mental illness
  12. Which family? What lens? Which practice?
    • Are we talking the same language?
    • Carer, Family, Parent-child, Family of origin, 'Parent consumer' Adult as Parent & Partner, Family of procreation or choice
    • Family sensitive practice, Family focussed practice, Child aware, FaPMI/COPMI practice
    • Trauma informed, Culturally sensitive, Strengths based
  13. The evidence exists..
    • In families of origin
      • More than 50 randomised control trials of Family Psychoeducation models over the last 35 years show:
        • significant reductions in relapse and hospital admission rates
        • improved adherence with medication, reduced symptoms and improved social functioning and vocational activity
        • reduce distress and burden in primary carers and improve family functioning
      • Some of these interventions are offered in Australia:
        • Behavioural Family Therapy
        • Multiple Family Groups
        • Family Consultation
    • In families of procreation or choice
      • A recent meta-analysis of the impact of family interventions on children in families affected by parental mental illness (Siegenthaler, Munder & Egger, 2012):
        • reviewed 13 RCT’s of family, couple or parent interventions
        • showed the risk of offspring developing the same mental illness as the parent was decreased by 40%
      • Some of these interventions are offered in Australia:
        • Let’s Talk About Children
        • Family Focus (in USA Family Talk)
  14. What hinders family engagement and recovery?
    • Barriers and constraints at the interpersonal level
      • Mother/Carer – ‘guilt in the marrow in my bones that I caused or contributed to this’
      • Consumer Parent – the emergency oxygen mask analogy
      • Child / Young Carer – ‘I don’t need a ‘better life’, just support to live it’
        • Effects of Stigma on self and others
        • Shame and Guilt
        • Loss and Grief
        • Fear of judgement, blame & losing child
        • Intergenerational experience & trauma
        • Challenge to sustaining Reciprocity & Role
        • Lack of Confidence, Trust & Hope
        • Past experiences of services & sharing
  15. Strategies for promoting family recovery
    1. Understand that recovery occurs in a family context
    2. Focus on strengthening parent–child relationships
    3. Support families to identify what recovery means for them
    4. Acknowledge and build on family strengths, while recognising vulnerabilities
    5. Assist family members to better understand, and communicate about, mental illness
    6. Link families into their communities and other resources
  16. Focus on strengthening parent–child relationships
    • Key messages
      • While difficulties in parent–child relationships are an important risk factors for ongoing problems for both parents and children, they are also one of the factors that is most amenable to change
      • Often, one of the most basic ways practitioners can support family recovery is to help parents reflect on if/how their mental illness affects their relationships with their children and partners and their capacity to provide parental care and to normalise support
      • Avoid making assumptions about the ways in which parental illness impacts on parent–child relationships
      • Narratives of other parents are powerful in the important task of validating, normalising and motivating and collaborating
      • Consider ways to support parents to connect with their child/ren even when their parenting capacity is may limited by ill health
  17. Focus on strengthening parent–child relationships
    • Example: Reducing the Impact of Hospitalisation – The KIT Menu
      • Reduce the trauma of disruption to the parent-child relationship
        • validate the critical life role of parenting
        • create conditions to maximise connection between parent and child; safe and planned contact and visiting; graduated decrease in the need for staff support in facilitating communication between as a consumer and child as condition improves
      • Reduce the stigma associated with parental mental illness
        • normalise parenting and children as ‘expected’ topics of conversation between staff, consumers and family members
        • reduces reluctance to seeking help and strengthens a major motivator to recovery
      • Help maintain and promote family resilience and well-being
        • support consumers and family members to explore their concerns and move through them together; strengthening their connectedness and open communication
        • support/resource consumers about how to talk with their children what is happening
        • seed idea of future advance planning – Baby\Child\Family Care Plans
    • Menu, Practice Guidelines & Visiting Policy
      • Downloadable from: http://www.copmi.net.au/get-info/copmi-publications.html
      • Produced by the Northern Psychiatric Unit, Northern Area Mental Health Service, Victoria.
      • Illustrations provided with kind permission of COPMI
  18. Focus on strengthening parent–child relationships
    • Example - Let's talk about children
      • 2-3 session intervention for parents with mental health issues
      • Developed in Finland by psychiatrist Tytti Solantaus
      • Collaborative process to engage parents in a conversation about their children without increasing guilt
      • A process that assists the practitioner and the parent using a developmental log to explore the needs of the child, the impact of mental health, and the supports they may need in their parenting role
      • Empowers parent to make changes in their family
      • This may include considering how children understand their parents mental illness and how parents may approach a conversation with their children about mental illness
  19. The parallel process of Let’s Talk
      Worker Parent
    Awareness raising Client as a 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

  20. Assist family members to better understand, and communicate about, mental illness
    • Booklets & Award Winning Australian Literature for Children and Young People
    • SANE guides, Dual diagnosis materials, Children's picture books, Teenage Fiction
  21. Assist family members to better understand, and communicate about, mental illness
    • Resources to support discussions
    • COPMI Booklets & Guides, Let’s Talk about Children Support Materials, Early Childhood & Teaching Resources
  22. A Lived Experience Perspective on Family Recovery - Gemma Olsen
    • Our Journey
    • Family, Identity and Recovery
    • What was key to our recovery?
    • Conclusion
  23. Our journey
  24. Family, Identity and Recovery
    • I'm not recovering in isolation
      • I am a mother
      • I am a daughter
      • I am a wife
      • I am a friend
      • I am Gemma
        • I am not just a person who experiences low moods and flashbacks due to trauma.
        • My father is not just a person who was experiencing psychosis in the 1990's & 2000's
        • My mother is not just a person who lives with severe ramifications of her own childhood traumas.
        • We ALL have people in our lives who are central to and have an impact on our recovery journeys (even if they are no longer in our lives).
        • We are ALL loved and needed.
  25. What was key to our recovery?
    • Key to our recovery journey has been:
      • Finding out who we are separate from the role of ‘carer’ or ‘parent with a mental illness’
      • Finding out who we are as a family that has been impacted by mental illness and …what does that mean for us?
      • Planning to know what to do if someone becomes unwell again
      • Knowing what help is available
      • Acknowledging the effect the past has had on us ie trauma, depression, finances, health
      • Valuing the lessons have we learnt
  26. What was key to our recovery?
    • Empathy and understanding
    • Being heard and understood
    • Having access to quality family focused programs - CHAMPS, LETS TALK etc..
    • Having fun together
    • Services working together and making appointments on certain days
    • Peer support
  27. Conclusion
    • There are many stories of family recovery - ours is just one.
    • The strength, love and care that I come across when working with families impacted by mental ill health never ceases to amaze me.
    • I wish you all the best with your work.
  28. Acknowledgements
    • This webinar is a collaboration between CFCA and Emerging Minds, through the Children of Parents with a Mental Illness (COPMI) national initiative.
    • The Children of Parents with a Mental Illness initiative is funded by the Australian Government
    • Brad Morgan, Director & Helen Francis Workforce Development Officer, Emerging Minds/COPMI
    • COPMI National Lived Experience Forum & Lived Experience Pool
  29. Questions?
    • Join the conversation & access key resources
    • Continue the conversation started here today and access a range of key resources, including the related practice paper, on the CFCA website: www.aifs.gov.au/cfca/news-discussion

This webinar was held on 11 August 2016.

Mental health recovery is an inherently social process, and family is the most important social context for recovery for many people living with mental illness. Estimates suggest that over 50% of people with severe and persistent mental illness have daily contact with their families, and roughly 20% live with dependent children. For many, it is simply not possible to separate their personal recovery journey from their roles and relationships within the family.

Drawing on research, practice wisdom and lived experience, this webinar encouraged professionals to consider how they can place family relationships and parenting at the centre of their efforts to support mental health recovery.

You may also be interested in a practice paper we've published on this topic: Supporting recovery in families affected by parental mental illness.

This webinar was a collaboration between CFCA and Emerging Minds, through the Children of Parents with a Mental Illness (COPMI) national initiative.

Please take a moment to read our Webinar Frequently Asked Questions.

Emerging Minds and COPMI logos

Key resources and further reading


The feature image was supplied by COPMI.

About the presenters

Rhys Price-Robertson

Rhys Price-Robertson is a PhD candidate at Monash University, where he is investigating the experiences of families affected by paternal mental illness. At the time of preparing this webinar, he was a Knowledge Broker for the COPMI (Children of Parents with a Mental Illness) national initiative. His most recent published research has focused on fatherhood, family recovery, family relationships, and child protection. Previously, Rhys worked as a researcher at the Australian Institute of Family Studies, and as a Div. 2 nurse in the aged care and mental health sectors.

Angela Obradovic

Angela Obradovic has worked in the clinical adult mental health field as a mental health social worker for over 23 years, and has been involved with the COPMI national initiative since 2002. As Chief Social Worker for an Area Mental Health Service in Victoria, Angela has led implementation of the Family Consultation and Multiple Family Group Models, Parent and Child Peer Support Programs and the Let’s Talk about Children intervention. Her recent research has included evaluation of cross-sectoral approaches to the care of families where a parent has a mental illness and the Victorian MIRF Project, Developing a Recovery Model for Parents in Victorian Mental Health and Family Services.

Gemma Olsen

Gemma Olsen is the mother of two beautiful children, aged 13 and 5, and lives in Victoria with her wonderful husband. Gemma's life has been touched by mental illness for as long as she can remember, and her lived experience includes being a child of a parent with mental illness and living as a parent with a mental illness. She also identifies as a Carer, as she has at times found herself in a caring role for her loved ones. Gemma now works in the mental health sector, endeavouring to create lasting change in the lives of people living with the symptoms of mental illness, Carers and families.

Comments

Hi, thanks for the input on this subject. I run supported playgroups and often have families who are grappling with many of the issues. The list of resources, especially the children's books, was really helpful.
Wendy