4 Nov 2013

Mr John Feneley

Mental Health Commission of NSW

Locked Bag 5013

GLADESVILLE NSW 1675

Email:

Dear Mr Feneley

Draft Strategic Plan for Mental Health in NSW

I am writing to make a brief submission in response to your invitation to contribute to the development of the Strategic Plan for Mental Health in NSW.

The Benevolent Society is Australia’s first charity, operating since 1813. We’re a not-for-profit and non-religious organisation and we’ve helped people, families and communities achieve positive change for 200 years. We help people change their lives through support and education, and we speak out for a just society where everyone thrives.

We provide services to families, children and young people, to older people and those with a disability, and to people with mental illness. We also work in communities to help build strong connections within families and across communities to promote resilience and wellbeing.

Our focus is to foster wellbeing throughout life – from infancy to older age with services that:

  • prevent problems or reduce their negative impact
  • tackle problems early before they become entrenched
  • help people use their strengths to solve their own problems
  • give priority to people experiencing social and financial disadvantage.

Many of our services work with people with mental health problems. For example:

  • More than half of the families that we work with through the Brighter Futures program have identified parental mental health issues , rising to almost three-quarters of families referred to us in the central western region of NSW.The Brighter Futures program, funded through the NSW Department of Families and Community Services, delivers targeted services to families with children aged under 9 years, or who are expecting a child, where the child/ren are at high risk of entering the statutory child protection system. Attached are two case studies that illustrate the way in which we assist families with mental health issues through this program.
  • Around a quarter of clients of our community care services (older people and people with a disability who participated a recent evaluation)had indications of serious psychological distress, while a further quarter recorded scores measured using the Kessler-6 scale indicating anxiety or mood disorders. Also included in our suite of community care services are ones that support older people living in squalor or hoarding, who tend to have long standing mental health issues.

In addition we run a number of services in NSW that are specifically aimed at supporting people with mental illness. These include

  • Personal Helpers and Mentors Scheme services (PHaMs) in Sydney metropolitan and regional areas
  • a Family Mental Health Service in Campbelltown
  • Headspace service in Liverpool
  • a mental health respite service in southern Sydney
  • community events that help build community understanding and celebrate the achievements of people with mentalillness, such as the See Me Hear Me Art Exhibitions.

In working with people with mental illness our aim is primarily to help people better manage their daily activities and access the support they need to participate fully in the community and build and maintain relationships, following the recovery model.

Acting early

We commendand are very encouraged by the Commission’s approach to developing the Strategic Plan as set out in The Life Course and the Journeys working paper, July 2013. We wholeheartedly support the focus in that paper on the whole of person, whole of life and whole of system. We note particularly that the paper identifies early childhood as a criticaltime when the foundations of mental health are laid and for fostering protection against future mental illness.

The Benevolent Society has a particularly strong commitment to encouraging governments to invest in early intervention to prevent problems before they reach crisis point or become much more difficult – and expensive – to address. We believe in acting early to enable children to reach their potential and contribute positively to our shared community. Investment in these early years is both more effective and brings greater economic returns to the community.

We recently commissioned the Murdoch Children’s Research Institute to review the evidence for early interventions to improve the wellbeing of vulnerable children and their families, especially those in disadvantaged communities. The report Acting Early, Changing Lives explores the link between early childhood experience and later health and wellbeing (including mental health) as well as examining the evidence as to which interventions are the most effective. I attach a copy of the report and commend its recommendations to you.

The report highlights the key early experiences and circumstances that can have life-long negative consequences on psychological health, including sustained poverty, child abuse and neglect, parental mental health problems and mental health problems in the early years.

Mental health disorders associated with child abuse or neglect include depressive disorders, anxiety disorders, drug abuse, and suicidal behaviour. Children who themselves experience mental health problems during the early years have an increased risk of range of sub-optimal outcomes in later life including: emotional problems in adulthood, poor educational achievement, earlier termination of schooling, and contact with the criminal justice system.

Our experience in working with children, families and adults bears this out, many of whom have had very difficult family backgrounds, sometimesspanning the generations.

Child development and family functioning are shaped by the physical and social environments in which they live, as well as by the effectiveness and responsiveness of the services available to them. Children who show resilience in the face of adverse circumstances are generally those who have been exposed to fewer risk factors for a shorter period of time and/or protected by positive experiences or compensatory mechanisms. The evidence suggests that maximising protective factors seems to be more effective than reducing risk factors.

The strongest influence on children’s development is the quality of the parenting they receive, and the nature of their home learning environments. These have effects on many areas of development, including self-esteem, academic achievement, cognitive development and behaviour. Optimising parent-child relationships and home learning environments are important goals for early intervention.

In addition, the quality of the relationships between parents can be just as influential. Marital conflict is associated with poorer outcomes in children and witnessing domestic and family violence can have profoundly damaging impacts upon children including long-term mental health problems.

Consistent with the Commission’s approach outlined in The Life Course and the Journeys, the report recommends that interventions to improve children’s life chances need to be multi-level:

  • program level interventions delivered directly to children and families;
  • community and service system level interventions that (a) target the nature of communities in order to improve social cohesiveness and social support to children, parents and families; and (b) interventions that target the service system that could take the form of, for example, building more co-ordinated and effective service systems; and
  • structural and societal level interventions that address the wider structural (e.g. government policy) and social factors (e.g. attitudes and values) that influence child and family outcomes.

Integrated child and family centres are a promising model for improving access to services, especially by disadvantaged families. They have been established in several other states but not in NSW (other than the federally funded Aboriginal Child and Family Centres currently under development). The key features of integrated child and family centres are that they offer parents and children access to a core set of services plus access to multidisciplinary assessment and services for anyemerging mental health (and other) needs, as required. Examples include the Early Years Centres in Queensland and the Tasmanian Child and Family Centres.

The Benevolent Society runs three of the four existing Early Years Centres in Qldas well as six satellite centres in the surrounding areas. The centres are service hubs supporting the health, development, wellbeing and safety of families who have young children up to the age of eight, including during the prenatal period. Services include early childhood education, care and health services which are offered at the centre, through home visits and outreach.

Older people

Last year the Benevolent Society produced a resource to provide guidance to community care practitioners in their day-to-day work of supporting older people,Research to Practice Briefing 7: Supporting older people who are experiencing mental distress or living with a mental illness. Through the Briefings, we are aiming to help build a culture of evidence-informed practice among community aged care organisations and practitioners.

Mental illness can be hard to detect in older people, as symptoms may not be reported, physical conditions may be of greater concern, or it may be difficult to differentiate mental illnesses from other psychological or physical conditions or dementia. It is a common misconception that mental illness and distress are a normal or inevitable part of ageing. The result is that when older people present with symptoms, nothing isdone even though they might be symptoms of conditions that are treatable. As a result the condition can worsen, become more difficult to treat and be very distressing for the older person and their family. Depressive symptoms, for example, can lead to reduced activity, social isolation, sleep and appetite disturbances, health problems, and even suicide – a significant problem for older men.

Strategic directions

We recommend the following strategic directions be reflected in the Strategic Plan for Mental Health in NSW:

  • Maintain and expand programswhich provide parenting and other support to vulnerable families with young children during the early years. Programs generally need to be at least 12 months long, and of some intensity to be effective. Brighter Futures is one such program. However its target group is families that have already come to the attention of the child protection system. Services that reach vulnerable families before this occurs – early intervention – are also required.
  • Increase the ability of mainstream child and family services to support children and parents with mental health issues. For example, through enabling families to have access to free child care during parental mental health crises, provision of programs through primary schools, and upskilling of child care workers to recognise family dynamics that place children at risk and child / parental mental health issues.
  • Invest in specific mental health preventive interventions that target childhood depression and childhood anxiety, for which there is good evidence of both effectiveness and good value for money[1].
  • Increase mental health services available to children and young people in rural and regional areas where there are long waiting lists for access to services.
  • Maintain and expand services that support people with mental illness holistically - with day to day living, with their physical health and that assist them to access services.
  • Improve local planning and collaboration between different parts of the service system, including state run services, federally funded services and professionals, and NGOs (irrespective of whether funded by state or federal governments). By ‘service system’ we mean not only the mental health service system, but also other services that work with people with mental illness.
  • Develop integrated one-stop-shop service models with multidisciplinary teams through which parents and children can gain easy access to core services needed by families with young children, plus access to assessment and services to address mental health needs, as required. Establish on a progressive universalism basis, i.e. giving priority to areas of disadvantage and high need but offering services to all in the local area.
  • Improve access to community based services after episodes of acute mental illness.
  • Enhance health and welfare service provider understanding and recognition of mental illnessamong older people, and expand treatment and other strategies to support them.
  • Continue strategies to change community attitudes towards and understanding of mental illness.
  • Over time, increase investment in prevention and early intervention strategies - to prevent mental illness and promote wellbeing. This will require cross-portfolio planning so that the problem of expenditure being incurred in one portfolio but the savings realised in another, does not hold back prudent investment.

Please do not hesitate to contact me if I can be of further assistance at 02 8262 3456 or . We would also be pleased to provide more information about our Early Years Centres, if this is of interest to the Commission.

Yours sincerely

Anne Hollonds

Chief Executive Officer

Caroline’s Story

Caroline, a 29 year old single mother of 3 year old David, was referred to Brighter Futures by the local Mental Health Team. Caroline had been previously diagnosed with Borderline Personality Disorder by a psychiatrist. Caroline also suffered from epilepsy and was on medication for both her mental health and epilepsy.

From the age of 7 until her mid teens, Caroline had experienced sexual abuse from a male family member. At the age of 11 Caroline informed her mother, but she was not believed and their relationship soon deteriorated.

Caroline and David lived with Caroline’s mother who was controlling and displayed regular emotional, verbal and financial abuse towards Caroline, belittling her and her ability to parent David.

When Caroline first engaged with the Brighter Futures program in 2012, she was often observed to be flat and teary throughout visits and disclosed suicidal thoughts. Caroline felt that she did not belong anywhere and that nobody loved her; she had constant visions and thoughts about the sexual abuse she had experienced but had no one to talk to. Caroline struggled to make friends and maintain them; her self esteem and confidence was extremely low and she found talking about her life extremely challenging.

Caroline was also struggling to parent David. She showed anxious attachment with David and found it difficult to allow him to interact with other children fearing he may get bullied or hurt. This meant that David had some difficulties in self-regulating appropriately for his age, for example biting himself and banging his head on the walls and floor when feeling overwhelmed. David often comforted his mother when he saw her crying or depressed.

The Brighter Futures Case Worker built and maintained a good rapport with Caroline and David respecting their life experiences in a non-judgemental way. Although building the relationship was a slow process it was one that gave Caroline a sense of worth and purpose and helped her identify her strengths and skills as a person and as a mother.

During their engagement with Brighter Futures, the Case Worker provided the following support to Caroline and David:

  • Enrolled in Brighter Futures supported playgroup
  • Enrolled in child care with financial assistance
  • Assessment with a community-based paediatric clinic
  • Therapeutic work with David to support the development of coping skills and promote a healthy relationship with his mother
  • Enrolled Caroline in a 10 week parenting program (Circle of Security)
  • Assisted Caroline to register with the local community housing provider to obtain her own premises to live an independent life with David
  • Encouraged and supported Caroline to continue counselling with the local Women’s Health Centre
  • Connected Caroline with the PHaMS team for mental health support to improve her coping skills, and engaged in case conferences with the local mental health team to work on shared goals
  • Provided Caroline with emergency contact numbers and safety plans for the times when she felt suicidal.

The Brighter Futures Case Worker also engaged Caroline’s mother in the program to encourage and support a healthier relationship with Caroline, which had a positive impact on David.

Outcomes: Caroline and David are both happy to be in the program and have regularly attended their appointments. Caroline has made friends with another mother in the Brighter Futures program and they often take their children to the park together. She is able to initiate conversations with her Brighter Futures Worker and other staff members, and is more confident advocating for herself and her son to seek support from other services.

Caroline is better able to identify when her mood changes and she is feeling down; she is able to implement coping strategies that support her through difficult moments and has gradually decreased phone calls to her Brighter Futures worker when in need.