Paper
Negotiating welfare and mental health systems: The experience of former adolescent milieu residents over fifteen years
- issue: Issue 3 / 2008
- authors: Patricia McNamara
- keywords: Australia, longitudinal study, welfare, mental health, adolescent
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- downloaded: 0
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abstract
Background. For many young people and their families, living with serious mental illness creates enormous vulnerability. Navigation of complex health and welfare systems often presents overwhelming challenges. This paper reports on the first Australian longitudinal study of former residents in an adolescent residential milieu. On an international level it is the first identified research on adolescent milieu treatment to incorporate a qualitative methodology. It is an intensive longitudinal study of eight adolescents admitted for an average period of four months around fifteen years ago. The research has been underpinned by an ecological-developmental conceptual framework; mixed methods were utilised at Stage One whilst at Stages Two and Three an ethnographic approach has been adopted. Transactions taking place within and between key systems in the former resident's ecological niche have been the primary focus. Systems under examination include family, school, workplace and community.
Aims and methods. This is research undertaken in three stages. At Stage One, the adolescents and their attendant ecological systems were studied at the point of admission, at discharge, at six months post-discharge. The primary aim at Stage One was to test a set of qualitative data gathering instruments with an ecological-developmental focus developed especially for the study. These instruments were positively received in the field; they have since been made available for clinical application.
Stage Two of the study qualitatively reviewed six of the original cohort and their parents through semi-structured interviews at around seven years post discharge. This ecological - developmental review process was continued at Stage Three in a fifteen-year follow-up with four of the former residents. The aim of Stages Two and Three was to track both ecosystems transactions and developmental progress (McNamara, 2007a; 2007b).
Findings. This study has spanned clinical, academic and political domains. At a clinical level, the very "thick descriptions" have offered a series of multilayered discontinuous narratives originally derived from the milieu experience and later from within the broader community.
The ecological-developmental framework applied here is consistent with that used in many therapeutic milieux. As a wide lens, this approach has allowed us to focus on the more subtle nuances of the person-in-situation configuration that extend way beyond the milieu. Dynamic inter-systemic transactions - both positive and negative - are revealed in stark profile. At times this is painfully confronting. However, it is clear that much can learned from examining these processes in such depth; both successful and unsuccessful clinical experiences are enormously informative (Curry, 2004).
Child, youth and family welfare systems have offered vital supports to families living with mental illness across the four generations studied. However, negotiating the interface between mental health and welfare systems has sometimes proved fraught for these former milieu residents and their families. The fifteen year narrative of one young woman illustrates that opportunity and challenge can often co-exist in this domain. Rachel first came to the attention of adolescent mental health services when she was admitted to a residential treatment program at the age of fifteen. Suicidal thoughts and behaviours and a range of immobilizing phobias had led to the admission. It was noted that Rachel's mental health problems appeared to mirror those of her father and paternal grandmother. That residential stay proved to be the first of many admissions through Rachel's adolescent and young adult years. Rachel's mental health problems gradually became attended by a complex set of social issues including homelessness, drug abuse and teenage pregnancy. Rachel has continued to live with mental health and social challenges since that time. At various critical points in her narrative however, welfare services have made a major difference to Rachel's life and to the lives of her parents and daughter Susie (now twelve years of age). Youth housing and education programs were difficult to access at first, but ultimately proved extremely helpful to Rachel. As a new mother, she and her family were greatly assisted by a Healthy Start Program; this appeared to improve Rachel's confidence and self esteem to the point where she was able to maintain long term employment and independent living. Recently however, breakdown of a long term relationship has led to a recurrence of serious depression and suicidal behaviour. Rachel has struggled to access both mental health support (especially counselling) and welfare services (such as respite foster care in a relatively remote rural community.
Lack of adequate supports has precipitated protective services involvement and the removal of Susie to the care of her maternal grandparents. Somewhat belatedly it would appear, child and family welfare services are now being explored to ensure that Rachel and Susie can be safely reunited.
Implications of the research. During the conduct of this research, policy implications have been continuously emerging. There is clearly an urgent need for mental health education for families and young people. Psycho-education can serve a powerful preventative purpose. It can assist in alerting consumers and caregivers to early signs of mental ill health, avoiding relapse and re-admissions. More effective systems transactions across the mental health-welfare interface would clearly help the service user and her/his caregiver to navigate what can seem an impenetrable labyrinth. Information about welfare rights and advocacy for mental health consumers seeking access to welfare services is also critical.
Cultural diversity is a phenomenon that is often unacknowledged within the milieu (Kruzich et al, 2002). Meanings about mental health are generally constructed within the dominant cultural paradigm. In this study, families of non-English speaking background struggled with the intrusions of an essentially "Anglo" milieu. Interpreting services were inadequate and usually inconsistent. Miscommunications due to cultural /sub-cultural difference were common. Research into trans-cultural issues within adolescent residential treatment remains extremely scarce, but is obviously much needed.
This study confirms that children, adolescents and adults living with serious mental illness still appear seriously marginalised from community based welfare and mental health supports. Throughout Australia the need is great; in rural areas it is acute. Improved access to both crisis mental health and welfare care and continuity of services are urgent imperatives. In Australia there is a growing awareness of the need to fund allied mental health professionals to undertake a far greater share of this work; in the past public funding has been largely limited to the too few psychiatrists accredited to offer such services. Broadening the professional service base might also offer greater support and advocacy to individuals and families as they negotiate mental health and welfare systems. It remains to be seen whether political rhetoric acknowledging the deficit is to be manifest in effective funding and programmatic shifts (House, 2005).
Key references
Curry, J. (2004). Future directions in residential treatment outcome research. Psychiatric Clinics of North America, 13(2), 429-440.
House, E. (2005). Qualitative evaluation and changing social policy. In N. K. Denzin & Y. S. Lincoln (Eds.), The SAGE Handbook of Qualitative Research. Thousand Oaks CA: Sage Publications.
Kruzich, J., Friesen, B., Williams-Murphy, T., & Longley, M. (2002). Voices of African-American families: Perspectives on residential treatment. Social Work, 47(4), 461-470.
McNamara, P. (2007a; 2007b) Fifteen years on: Conversations with former adolescent milieu residents. Parts I and II (forthcoming).
Contact: Patricia McNamara, School of Social Work and Social Policy, La Trobe University, Bundoora, VICTORIA, 3068, Australia, E-mail: p.mcnamara@latrobe.edu.au, Phone +61 3 94795681, Fax +61 3 94793690.