Submitted on 4 July 2019
What are your suggestions to improve Victorian community’s understanding of mental illness and reduce stigma and discrimination?
There has frequently been a disproportionate focus on adult mental health issues, and early intervention is often understood within adult mental health parameters. This perspective does not adequately address core developmental aspects of mental health. We recommend a paradigm shift in early intervention. From a frame of infant and child psychological, mental and neurobiological development, any health promotion campaign which focusses on the critical nature of the infant and mother (or primary care-‐giver) attachment relationship to an infant’s mental health trajectory is highly recommended. While an understanding of the concept of ‘mental health’ has possibly improved over recent years, it is still predominantly understood within a medicalised model of psychiatry with less emphasis upon the origins of the difficulties. A medicalised model may underplay the complexity of mental health/illness and diverts attention away from psychological and sociological factors including poverty, disadvantage, and impoverished early attachment relationships with caregivers.
To reduce stigma, mental illness might be better served being viewed through the lens of bio/psycho/social/developmental factors, which emphasise the importance of healthy attachment relationships and the origin of the difficulties (often but not always stemming back to earliest years). This wider lens allows for the possibility of moving through mental illness to mental health, with the help of appropriate support services, including psychotherapies which privilege the development of a healthy sense of self in the context of family history and the quality of relationships.
Public education forums in the community, including to parents and teachers, about the psychological development of infants and children, which incorporate recent research into neurobiology, attachment theory, trauma theories and theories of the developing mind would be an additional way to shift an understanding of mental health at a community level.
Assisting the Victorian community to understand the importance of the secure attachment relationship between mothers/primary caregivers, infants/children and adolescents is an important step to understanding the value of early intervention as relating to early in life. Empathic and sensitively designed campaigns may begin to shift the understandings of the origins of mental health difficulties and raise awareness of risk factors to infant, child and adolescent mental health.
We recommend public education forums in the community and workshops targeting adolescents within schools about the psychological development of infants and children, incorporating neurobiology research, attachment theory, trauma theories and theories of the developing mind. These would be an additional way to shift an understanding of mental health at a community level. In addition, education programmes designed to promote and encourage empathy, demonstrating ‘empathy’ as an indicator of good mental health and aimed to assist in reducing stigma and discriminatory ideas associated with mental illness.
We recommend that health promoters consult with trained Infant and Child Psychotherapists and specifically Child Psychoanalytic Psychotherapists in developing the desired messages of such campaigns.
What is already working well and what can be done better to prevent mental illness and support people to get treatment and support?
Within the professional mental health sector, perinatal mental health is widely recognised as a determinant of child, adolescent and adult mental health (World Health Organisation WHO, 2013) and Victoria is known for it’s provision of specialty in-‐patient services for mothers and infants, admitting around 1000 mothers per year in Melbourne. (Brockington, Butterworth, Glangeaud-‐Freudental, 2017).
It is our collective understanding that Victorian State Government have committed to a 10 year plan ‘Victoria’s 10 year Mental Health Plan’, (Department of Health and Human Services (DHHS), 2015). The desired outcomes relating to children and families are;
“5/Early in life - infants, children,young people and their families are supported to develop the life skills and abilities to manage their own mental health
7/Families and carers – the role and needs of family, kinship community, and carers of people with mental illness are respected, recognised, valued and supported.” (p.2, DHHS,
These outcomes are only achievable with an ongoing commitment to fund the required intensive therapeutic services for vulnerable families often identified through their involvement with other government agencies/services (such as DHHS Child Protection services). Many families who come to the attention of this Department require assessment and therapy. Infants, children and young people are often unable to simply ‘learn the life skills and abilities to manage their mental health’ as they have not experienced or gained
the necessary scaffolding from their earliest relationships to be in the position to make use
of this learning. A child who has experienced insecure/avoidant/disorganised attachments and has therefore developed a relationship template characterised by mistrust of adults and avoidance, will require compensatory experiences before they are able to learn to look after themselves and their own mental health. This kind of mental health support can best be achieved within a therapeutic relationship. When deficits are substantial, these are best addressed with one consistent, long-‐term therapist who is able to see the child at least on a weekly basis for several months/sometimes years. While it might be of concern that this is an expensive investment, long term and retrospective studies indicate that a child who receives long term psychotherapy will gain the protective factors such as ‘greater resilience to stress and better outcomes in terms of relationships and emotional wellbeing’. (Fonagy, Steele, Steele, Higgitt, & Target, 1994; Fonagy & Target, 1997a, 1998). The aim is to prevent a trajectory towards repeated placement breakdown, homelessness, the criminal justice system or further involvement of Child Protection inter-‐generationally. We ask that this proposal be given due consideration by the Royal Commission.
Many families who are involved with government department systems such as Child Protection or Youth Justice may require mental health treatment. Due to entrenched patterns of relating to children, parents involved in the Child Protection system often require long term, regular mental health services to support their ability to parent in ways that optimise mental health protection to their children. In cases where there has been considerable previous involvement of Child Protection, the provision of financial assistance
or funded programs to provide long term, relationally based therapy to parents and children
is of paramount importance.
Those who provide care for children who have been removed from their families resulting from the substantiation of child neglect or maltreatment such as foster carers, kinship carers and residential carers, have been left largely unsupported. While there are some therapeutic foster care/residential care programs currently funded, there is a desperate need for all foster carers and residential carers to be provided with initial training in the effects of trauma on child mental health. Foster/kinship/residential carers need ongoing therapeutic support and parenting guidance for themselves as carers of traumatised children. We recommend they receive frequent and consistent mental health consultancy and support to help them respond therapeutically to these children who present with a range of trauma related symptoms. Programmes or models which provide a thorough assessment of the child through a developmental, attachment and trauma lens and offer treatment to the child in addition to ongoing support to carers such as “TRACK Therapeutic Foster Care” and “Circle Therapeutic Foster Care” currently funded by DHHS in partnerships with Australian Childhood Foundation and Take Two, Berry Street Victoria need to be expanded to provide such services across all children and carers in Victoria. (Both programmes have had very positive independent evaluations).
A seamless interface between foster care agencies, child protection practitioners and mental health services is yet to be established. We recommend identifying and addressing the potential for gaps in provision to these children and families by facilitating services and clear communication between these sectors.
It is reassuring that the State’s plan recognises that achieving positive mental health at a community level is not something that can be achieved in a short term, it takes time.
We recognise that therapy to heal those who suffer from poor mental health also takes time and make recommendations to Government accordingly.
We believe that good mental health trajectories begin within healthy, holding and containing relationships between primary care-‐givers (usually mothers) and infants. The discussions regarding mother, infant and child mental health within the recent Australian Mental Health report (Australian Institute of Health and Welfare, 2018, p.27), make reference to the ‘mental health workforce’ as psychiatrists, nurses, psychiatric nurses and psychologists. We request that the definition of our ‘mental health workforce’ in Victoria needs to be broadened to include trained infant and child psychotherapists who are specifically trained to provide relationally-based assessments and therapeutic treatment services to infant-‐mother dyads, children, adolescents and parents. Child psychoanalytic psychotherapists hold additional specialised qualifications which reflect their intensive training in both the development of infants, children and adolescents and in the delivery of effective psychotherapy. Child Psychoanalytic Psychotherapists practice both within public and private systems in providing long term, evidence-‐based and relationally-based treatments that are pitched to each individuals developmental stage.
We recommend that psychotherapists be recognised under the Medicare Rebate scheme (Better Access Initiative). The Medicare Rebate scheme is currently woefully inadequate to meet the therapeutic needs of these children and families. This scheme is currently time limited (5-‐10 sessions) and often barely allows enough financial support for an assessment of the child/patient let alone full treatment. For sustainable outcomes for our most vulnerable populations, such as stated in no.5 and no.7 in the Victorian 10 year Mental Health plan, a recognition and commitment to funding of programmes or financial health support schemes/initiatives is essential. The Australian Psychological Society (APS) White Paper on Medicare Rebates recognises the need for and recommends longer treatment.
What makes it hard for people to experience good mental health and what can be done to improve this? This may include how people find, access and experience mental health treatment and support and how services link with each other.
Good mental health is less reliant upon good mental health treatment than upon good relationships, specifically secure attachment relationships which grow subsequently from primary secure attachment relationships in infancy and early childhood. Good relationships experienced in the earliest days and weeks of life are the most critical protective factor to good mental health. If a child has experienced a secure attachment with their primary care-‐giver, they are likely to experience satisfying secondary relationships with family, friends and eventually partners in adulthood. Good and satisfying relationships reduce the incidence of mental health difficulties and provide for a support network for those who do. Unfortunately, many of those who present with severe mental health difficulties have not sufficiently internalised a nurturing and supportive relationship and
have therefore struggled in finding and maintaining supportive friendships through their
lives. If it were not the single cause of mental illness, social isolation has possibly magnified and perpetuated their mental health difficulties. An understanding of this phenomena is formally recognised in a publication about the social determinants of mental health developed by the World Health Organisation. It pronounces as a key message:
“While comprehensive action across the life course is needed, scientific consensus is considerable that giving every child the best possible start will generate the greatest societal and mental health benefits”. (WHO, 2014, p.8)
We advocate for a mental health system that recognises and acknowledges that a “best start” is a secure primary attachment between an infant and their primary care-‐giver. All systems that deal with parents, infants and children require current and relevant training in Attachment Theory, Infant and Child developmental theory and Trauma theory so that they may contribute to the support of healthy primary care attachments. The mental health workforce, including psychotherapists need to be provided with funding to provide consultancy, education and training in addition to providing assessment and therapy.
Working collaboratively with Victorian Police, the Victorian Juvenile Justice System, the Victorian education system, Child Protection, Victorian Early Childhood Services and Maternal and Child Health care system requires an intentional plan from Victorian government to provide for mental health consultancy that provides adequate current education and guidance to the full spectrum of professionals within these services a thorough understanding of attachment theory and the impacts of attachment disruption and trauma on our mental health trajectories. With current figures suggesting that an 80% growth in expenditure in prisons for Victoria over the 2011-‐2012 to 2017-‐2018 periods (Millar and Vedelago, 2019)n, we want to draw attention to the 65% of women incarcerated who have experienced family violence and the strong likelihood of their criminal behaviour resulting from trauma and mental health difficulties. Investing into the most preventative forms of mental health help such as child psychotherapy.
What are the drivers behind some communities in Victoria experiencing poorer mental health outcomes and what needs to be done to address this?
In our work with children and families as child psychotherapists, it is apparent to us that there are range of difficult circumstances that families face which, may play a role in the disruption of healthy attachments and may precipitate, perpetuate or exacerbate mental health difficulties in children. Often we see that children with the most severe difficulties are from families where parents have experienced the same challenges and traumas in their own childhoods and this may have occurred for multiple generations. This intergenerational aspect of mental health is being explored in the realm of epigenetic research and suggests that there is an interplay of both nature (genes) and nurture (trauma) in how mental health symptoms are formed and expressed. Communities who experience poor mental health outcomes are likely to have experienced complex trauma, may be from a traumatised group such as indigenous/stolen generations, suffer from cumulative or complex trauma related to family violence, poverty, substance use problems, have attained lower levels of education and lower levels of employment and have higher rates of criminal behaviours. Addressing the determinants from upstream such as socioeconomic hardship, reduced access to education, training, employment opportunities may be one way to address the imbalances in who experiences mental health difficulties.
What needs to be done ?
Pro-active and preventative measures on a community level that involve early detection of vulnerabilities. This should be followed by the engagement of highly specialised and consistent therapeutic care to address the deficits in the child’s environment. This will realistically only occur in a timeframe relative to the time in which a child has been immersed within a dysfunctional family setting. This is why early intervention is so critical for effective therapeutic benefits to the child as an individual and which then flows to the community. It also makes sense in terms of cost effectiveness of the services provided.
What are the needs of family members and carers and what can be done better to support
Often when a child is experiencing mental health difficulties, it is necessary that the parents/parent/carer of that child also requires therapy. While a child might hold the symptoms, these symptoms may be the result of interpersonal, family dynamic and
intrapsychic conflicts which are best resolved through both the provision of therapy to the child and coinciding parenting therapy to parents. Not only does this allow for a full exploration of the potential predisposing and precipitating factors relating to the child’s symptoms or difficulties but will allow for a deeper level of understanding within that parent of their child and how they may need to respond to them.
In the cases of children who live in kinship or foster care, the provision of parenting therapy to carers allows carers to hold a more complete picture of the child they are caring for and to know how to provide an environment which will build and strengthen that child’s internal resources while providing compensatory experiences of a more secure attachment to the child. Foster carers and Kinship carers are in urgent need of sustained therapy
support from the mental health workforce. Child psychotherapists with their comprehensive
and expert training are well positioned to provide this specialised therapeutic work and also to provide specialised training for the mental health workforce. Currently there are programs being offered through Berry Street Victoria and Australian Childhood Foundation, funded by the Department of Health and Human Services (DHHS), however these programmes are stretched with high case loads and waiting lists. These programmes need expansion across the entire Childrens’ Out of Home Care sector.
What can be done to attract, retain and better support the mental health workforce,
including peer support workers?
Child and Adolescent Mental Health Services (CAMHS) need to be supported with fully multidisciplinary teams. Over many years there has been a diminishment of these valuable services in providing a full multi-‐disciplinary model of assessment and therapeutic care to children and families. These public services have the potential capacity to provide comprehensive therapeutic services to vulnerable children and families. Programmes offered through Berry Street’s Take Two and The Australian Childhood Foundation are examples of other avenues for the public system providing enhanced and comprehensive therapeutic services to children and families within the child protection system. However, the current arrangements require staff in these programmes to hold high case-‐loads for minimal remuneration and limited administrative supports. These issues require understanding and addressing to ensure staff can be retained.
Therapists of this calibre need to be remunerated appropriately and provided with employment conditions to reflect the level of difficulty in this work. The potential for vicarious trauma in therapists needs to be recognised and addressed. Providing all clinicians within this mental health workforce with regular high-‐quality, clinical supervision and opportunities for reflective practice would be recommended at the most basic of levels to prevent ‘burn-‐out’ symptoms or other vicarious trauma related risks.
Thinking about what Victoria’s mental health system should ideally look like, tell us what areas and reform ideas you would like the Royal Commission to prioritise for change?
Training provided to ensure early detection of potential mental health difficulties in mothers and infants, by maternal child health, health and child care professionals.
Early intervention including therapeutic services for infants and their mothers, children and parents, adolescents and their families.
Better linkages between social/human services for children and families.
Therapeutic support provided to all foster carers and those responsible for the care of infants and children who have experienced disrupted attachment and/or trauma.
Mental health practitioner/providers to be funded to offer consultancy and training roles within early childcare and schools within Victoria to assist all schools to be equipped to support children who have experienced trauma or are experiencing mental health difficulties.
Is there anything else you would like to share with the Royal Commission?
There is an alarming increase in the number of children and adolescents presenting to child, adolescent and family services across Australia (and beyond our shores) with complex and severe emotional disorders (Shonkoff & Phillips, 2000; State of Victoria, Royal Commission into Family Violence (2016); Valentine & Katz, 2007).
These can include a range of behaviours and symptoms causing emotional distress severe enough to warrant specialist attention. Disturbances seen in these services (but by
no means a comprehensive list) embrace some of the following: infant mental health issues such as excessive crying, sleep disturbance, failure to thrive, mother-‐infant interaction difficulties, post-‐natal depression, attachment disruptions and attachment disturbances; aggressive and oppositional behaviours in children of all ages, sexual, physical, emotional abuse and neglect, witnessing family violence, ADHD, ASD, poor peer relations and withdrawal in children and adolescents, learning difficulties, eating disorders, depression, and self-‐harm. Research tells us that these disturbances and difficulties need to be addressed early in life, otherwise they can lead to later disorders of mental health, substance abuse, and criminality in adulthood. Mental health difficulties may diminish a person’s likelihood of finishing school, finding employment and becoming a productive member of society. ‘Studies have demonstrated that the economic costs of this lost productivity far exceed government expenditures.’ (Doran, D.M., 2013 p7). ‘Early intervention has been shown to achieve, at relatively modest cost, changes to prevent
harms that are very expensive to remediate. The lifelong harms associated with child abuse
and neglect, problems in school, and early behaviour problems include adult criminality and loss of life …… Research demonstrates that, to be effective, early intervention programs must be long term, evidence based and comprehensive’ (Valentine & Katz, 2007, P1).
Shonkoff and Phillips (2000) in their seminal publication FromnNeuronsnton Neighbourhoods note the importance of professional training: ‘individuals with pertinent expertise to work in settings with young children are essential first steps toward more effective screening, early detection, treatment, and ultimate prevention of serious childhood mental health problems’ (p6).
There is also now extensive evidence-‐based research on the efficacy of Child and Adult Psychoanalytic Psychotherapy in both short-‐term and long-‐term work for the most unwell and complex children and adolescents. Fonagy , Cottrell, Phillips, Bevington, Glaser & Allison (2015) in their comprehensive critique What Works for Whom? A critical Review of Treatments for Children and Adolescents document effective treatments and programs covering a range of different approaches. They suggest models of stepped-care to meet the needs for effective psychological interventions for the widest range of those seeking help. Psychodynamic psychotherapy for parent-child dyads was found to be effective with maltreatment and family trauma and individual psychotherapy helpful for younger children with anxiety disorders. Adolescents suffering serious mental illness were helped by intensive psychoanalytic psychotherapy in a research study Time for A Future conducted in CAMHS services in the State of Victoria (Tonge, Pullen, Hughes & Beaufoy, 2009). Child psychoanalytic psychotherapy can be a therapy of choice for complex cases when other therapeutic approaches have not been suitable for some children and adolescents.
Child Psychoanalytic Psychotherapy is one of a spectrum of psychological assessment and treatment modalities that are effective with disturbed children and families. Victorian child and adolescent mental health services recognize these disorders may require a period (including those needing an extended period) of specialized treatment. Child and Adolescent services offer a range of effective therapeutic approaches, Child Psychotherapy being one such offering available to children, adolescents and families. This therapeutic diversity enhances services’ capacity to meet the variety of individual client needs and presenting problems of children, adolescents and parents.
This submission was written and prepared by Yvette Willoughby, Dr Jennifer Re, and Nada Lane, for the Child Psychoanalytic Psychotherapy Association of Australia.
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