Resourcefulness and Resilience: The Experience of Personal Recovery for Mothers with a Mental Illness

Resourcefulness and Resilience: The Experience of Personal Recovery for Mothers with a Mental... Abstract Understanding of key characteristics and processes of personal recovery from mental illness is growing. However, a paucity of research exists with mothers with mental illness around experiences of personal recovery. An improved understanding of the interplay between illness, parenting and broader social factors may better inform how mental health services respond to the needs of these women. Using constructivist grounded theory (CGT), in-depth interviews were conducted with seventeen women who were mothers with a mental illness, residing in Australia. Through the CGT technique of constant comparative analysis, initial codes were synthesised and theoretical sampling employed to reach saturation of the categories associated with the construct of personal recovery. For mothers with a mental illness, personal recovery takes place within and is shaped by broader social contexts. Six key dimensions of personal recovery were ‘recognising recovery’, ‘mothering’, ‘experiencing oppression’, ‘managing distress’, ‘making a change’ and ‘feeling better’. This study found that mothers with mental illness interpret recovery as enduring through difficult times, rather than a process of personal transformation and adjustment which is articulated within personal recovery literature. Well-being outcomes for women with children may be more effectively promoted through strategies that address underlying factors such as supporting early mothering, preventing violence against women, addressing trauma, and redressing socio-economic disadvantage and gender disparity. Personal recovery, mental health, mothering, trauma-informed care Introduction Personal recovery As part of multidisciplinary teams, social workers are advantageously positioned within mental health services to be able to promote recovery from mental illness. Social workers are also employed across a range of family settings including early years, child protection, drug and alcohol services, and community health, where they may encounter maternal mental health difficulties. As mental health services re-orientate towards a personal recovery focus (Wyder and Bland, 2014), social work training prepares practitioners to respond with family-focused practice (Maybery et al., 2014), community development approaches (Forde and Lynch, 2015) and understanding of socio-economic and political enablers and barriers to recovery (Bowen and Walton, 2015). Recovery is broader and more complex than narrow medical constructions (Deegan, 1996; Slade, 2009) and defined to include living ‘a satisfying, hopeful and contributing life’ (Anthony, 1993, p. 13), developing ‘a sense of integrity and purpose’ (Deegan, 1988, p. 15) and building ‘connection, safety, hope, and acknowledgment of (one’s) spiritual self’ (Long, 1994, p. 4). Implicit is that recovery can occur even when psychiatric symptoms persist. Built upon thirty years of momentum, personal recovery is now the guiding principal underpinning the Australian national mental health services policy and practice (Commonwealth of Australia, 2010, 2013). Equally, in 2012, trauma-informed care practice guidelines were developed for universal implementation across settings, in recognition of the high prevalence and profound implications of trauma on individuals with mental illness and their families (Kezelman and Stavropoulos, 2012). The conceptual basis of personal recovery was recently strengthened by the undertaking of a systematic review of eighty-seven articles exploring personal recovery and mental illness (Shanks et al., 2013). Connectedness, Hope and optimism, Identity, Meaning in life and Empowerment were confirmed as key principles underpinning the recovery concept (Leamy et al., 2011). While validating a CHIME framework, the review illustrated that personal recovery is rarely viewed from a mother’s perspective. Parenting with a mental illness is not mentioned in the review of the eighty-seven studies. Mothering with mental illness Only 16 per cent of Australian women remain childless into their forties (Australian Bureau of Statistics, 2008) and it has been observed that ‘motherhood, which is often an intensive and lifelong relationship for women, can have a significant impact on women’s identities’ (Laney et al., 2015, p. 127). It is estimated that over 50 per cent of women with mental illness are parents (Maybery et al., 2009; Parker et al., 2008) and recognised that the challenges of parenting can impact on mental health (Ackerson, 2003), while mental illness symptoms, treatment and associated difficulties can compromise parenting capacity (Montgomery et al., 2006; Venkataraman and Ackerson, 2008) and impact on all family members (Reupert and Maybery, 2007). However, parenting is rarely alluded to in personal recovery discourse (Nicholson, 2014). Conceptually, personal recovery has been about individuals, with carers of those in recovery receiving occasional mention (Wyder and Bland, 2014). Rarely is the perspective of mothers with mental illness caring for children included in personal recovery discourse. Mothering is highly gendered (Chodorow, 1978), socially and culturally constructed (Hays, 1996) and at times difficult and demanding (Hays, 1996; Ussher, 1991). Women with a mental illness face additional parenting challenges, including symptoms and treatment (Ackerson, 2003), socio-economic disadvantage (Luciano et al., 2014), difficult family relationships (Perera et al., 2014), and community stigma (Seeman, 2010) and discrimination from health service providers (Cremers et al., 2014). These latter issues at times result in women’s recovery being compromised due to masking symptoms when they are unwell, to reduce the risk of separation from their children through custody loss (Montgomery et al., 2006; Venkataraman and Ackerson, 2008). However, the experiences and needs of mothers with mental illness require greater understanding. This study examines the experience personal recovery from mental illness from the perspective of rural women who are also parents. The study investigates the characteristics and processes that rural mothers found to be significant in their recovery journey, including the factors that facilitate or impede recovery. Rural women were selected as participants as they are under-represented in studies exploring the impact of mental illness and it was considered that their needs and experiences may differ due to their rural location. Methods Following ethics approval from two health service and one university Human Research Ethics Committees, women were informed of the study via mental health clinicians and social and print media. Women were screened for eligibility (one child aged under eighteen years in their care at least 50 per cent or the time, self-identified psychiatric diagnosis and living rurally) and participants gave written informed consent. Ten (of seventeen) participants had current or past involvement with a mental health service and their backgrounds are illustrated below. Interviews (three by phone and seventeen face to face) were audio recorded and transcribed verbatim and conducted by the first author. The flexible interview schedule asked mothers about their perspectives and experiences of their illness, motherhood and their personal recovery. Examples of open-ended questions included: Tell me about your mental health difficulties. What does recovery mean to you? How has becoming a mother changed the way you see yourself? Data were analysed concurrently with data collection using a constructivist grounded theory (CGT) approach (Charmaz, 2014), initially through line-by-line coding whereby every line of data was coded with a gerund that described the social or psychological process occurring. Focused coding was then undertaken, facilitated by memo writing and mind mapping (Charmaz, 2014). During this process, those codes with ‘more theoretical reach, direction and centrality’ (Charmaz, 2014, p. 141) were raised to categories. The properties of those categories including the circumstances under which they transpired were explored. Emerging ideas about relationships between codes and categories were represented pictorially (Figure 1). Figure 1 View largeDownload slide Personal recovery conceptual map Methods: This conceptual map was developed as a visual representation of the data analysis following the conducting of in-depth qualitative interviews with seventeen women who were mothers with mental illness, residing in rural locations. Employing constructivist grounded theory methods (Charmaz, 2014), constant comparative analysis commenced with line-by-line coding, followed by focused coding facilitated by memo writing and mind maps. Results: The circles connected by arrows within the map represent the categories that describe the process of personal recovery: managing distress, making a change and feeling better. The words and phrases within these circles define the properties of the category. The arrows between the circles describe the possible routes within the journey. The outer sphere encompasses the social and societal environment within which personal recovery takes place. Prominent in this is the experience of mothering, rural settings and cultures, and the experience of oppression related to the mental illness, poverty and disadvantage, gender inequity and/or social isolation. Figure 1 View largeDownload slide Personal recovery conceptual map Methods: This conceptual map was developed as a visual representation of the data analysis following the conducting of in-depth qualitative interviews with seventeen women who were mothers with mental illness, residing in rural locations. Employing constructivist grounded theory methods (Charmaz, 2014), constant comparative analysis commenced with line-by-line coding, followed by focused coding facilitated by memo writing and mind maps. Results: The circles connected by arrows within the map represent the categories that describe the process of personal recovery: managing distress, making a change and feeling better. The words and phrases within these circles define the properties of the category. The arrows between the circles describe the possible routes within the journey. The outer sphere encompasses the social and societal environment within which personal recovery takes place. Prominent in this is the experience of mothering, rural settings and cultures, and the experience of oppression related to the mental illness, poverty and disadvantage, gender inequity and/or social isolation. As per the CGT methodology (Charmaz, 2014), following the tenth interview, theoretical sampling techniques were undertaken to further examine ambiguous or incomplete elements within the emerging data. An additional ten interviews were conducted (three being second interviews with existing participants, seven with new participants) with a revised interview schedule to explore further the meaning and processes of personal recovery. As codes emerged, the researcher purposefully recruited to the study participants who had characteristics that enabled them to provide additional data that deepened understanding of the properties of the emerging codes (and subsequently the categories). This is consistent with CGT methodology, and multiple interviews with the same participants is a common process as the data analysis process is both emergent and inductive (Charmaz, 2014). New data are compared with previously gathered data, which may result in fresh insights or the highlighting of a code as significant, warranting further exploration in relation to its meaning and the circumstances under which it occurs. Components of the data were coded by two researchers. Discussion between all three authors enabled consolidation of categories and promoted reflexivity. Participants Twenty interviews were held with seventeen women. Women were aged between twenty-three and fifty-three years, and had an average age of 36.29 (SD = 8.27). Cultural background was described as Australian for ten participants, Australian/English for two and Australian/German for one woman. Two women identified as having Aboriginal heritage, while an additional woman identified as part of the Aboriginal community through being a mother to Aboriginal children. The remaining participant stated that her biological parents were Italian and Finnish, although she had grown up in an adoptive Australian family. Self-reported diagnoses included bipolar disorder (five), borderline personality disorder (two), anxiety (nine), psychosis (two), depression (eleven), post-natal depression (four) and obsessive compulsive disorder (two). Fourteen women reported having two or more diagnoses. Participants had a total of thirty-seven children, averaging 2.18 children per family. The average age of children was 8.27, with a range from six months to seventeen years. Eight of those children were living in out-of-home care at the time of the interview; however, all but one women had at least one dependent child living with them. Eight participants relied on a government payment as their primary source of income, while two were employed full time, four were supported by a combination of their partner’s wages and their own part-time wages, and two derived an income from the family farm. The majority (n = 9) of women lived with their partner and children, four lived with their children only, one lived alone and two lived with their child and their parents. Nine of the women owned or were buying their home, five lived in private rental and three lived in public housing, one of these being transitional housing. Findings The following sections detail the categories emerging from the data relating to personal recovery. Recognising recovery Of the seventeen women interviewed, seven were familiar with the term ‘personal recovery’ at the outset of the interview. Those who were familiar had all had a long-term relationship with a psychiatric rehabilitation service (which in Australia is a community-based organisation which promotes psycho-social recovery and rehabilitation) instead of or in addition to a clinical mental health service (which is more likely to be focused on promoting clinical recovery through medical and psychological therapies). One woman who strongly related to the term stated: Recovery to me … is seeing myself beyond the illness. It’s about moving forward in life. It’s about getting back into study, it’s about educating yourself and wearing the illness so that you know you can walk through any door and you know that you’re unique inside, that you’ve got it in yourself, you can help someone else. All participants, regardless of their familiarity with ‘personal recovery’ in mental illness, were able to conceptualise how it might be relevant for them. Concepts associated with recovery included acceptance, normalcy, validation, emotion regulation, personal insight, gaining understanding, seeking support and making conscious changes. Acceptance was multifaceted and included acknowledgement of an underlying problem, a diagnosis, the need to take medication, the need to access services and supports, and acceptance of personal responsibility for initiating change. Being diagnosed and prescribed the correct medication are more closely aligned with clinical recovery outcomes; however, one woman described significantly improved cognitive function on commencing medication: When I used to think, it was like a freeway, like a fifty lane freeway of thought … all just going at once, and I can’t stop it, I can’t help it. It frustrates me … but with the tablets I am able to just slow it down. I can pick one, and I can have it slowed down even more, and I can concentrate on that line. It makes things a lot clearer, which makes it better. Recovery was described as a process that is unique, individual, ongoing and active, requiring conscious effort and commitment: ‘… recovery, can start with a beginning … a realisation that there is something wrong, really wrong, I need to help myself.’ One participant regarded recovery as impossible for her, seeing her symptoms as ongoing and persistent barriers to achieving 100 per cent clinical recovery, thereby dismissing other measures of recovery. She also commented that she regarded herself as a ‘normal’ mother, undertaking the same tasks as other mothers with equivalent competence, highlighting that mothering competence and confidence can occur while mental illness persists. Women related less to the concept of personal recovery than to the notion of enduring through continuing episodes of mental illness. Along the way and through personal reflection, they learned more about themselves and the factors that were likely to place stress upon them. They also developed skills to deflect the negative responses of others and resourcefully sought more helpful sources of support, whether that be via online forums, through health services or through developing friendships with like-minded peers. Through hearing the experiences of others, women learned to be less self-critical and to increase self-care activities that they had found to be effective: There’s just a lot of healing these days where I just don’t want to get up but I do. With my boy, he’s got school and I get up with him …. And if I go back and lie on the couch and sleep for an hour when he’s gone, sometimes I do that, I need that. Mothering The mothering role was dominant in women’s lives, and they spoke of their love and devotion to their children, in tandem with the values they wished to impart, such as independence, kindness, respect and a strong work ethic. However, for women with limited social and financial resources, the relentless labour of parenting was also apparent, and participants shared their struggles in attempting to provide for their children’s needs, aware that this left them depleted in time, energy, finances and other resources. Women articulated an understanding of the cultural expectations surrounding mothering, and aspired to meet them, conceding that their own needs were on hold until the children grew older because ‘that’s what being a mother is about—the kids’. While half of the women spoke of their desire for closer peer relationships with other mothers, their attempts at connection in settings such as new mothers groups often left them feeling as though they did not ‘fit in’ and ‘this divide or wedge got bigger and bigger’ due to differences in socio-economic status, cultural background, language or age. The demands of mothering influenced opportunities to source resources to promote recovery. However, recovery outcomes were also seen to benefit children, as women sensed that their wellness would provide security and hope for their children. Their hopes around the future were centred on being able to manage emotions, symptoms and challenges, with their mental illness diminishing in influence. Women aspired to enjoy more happiness and ‘just a bit of freedom’ rather than being overwhelmed by anxiety, sadness or confusion, ‘so when the kids come home they can see me on fire and they can see Mum leading a whole healthy life and not tortured by the past’. Experiencing oppression The social context of participants’ lives was found to be highly influential for promoting or hindering access to the personal, social and economic resources required to promote recovery from the mental illness and its effects. Oppression took many forms. The most profound was gender-based and manifested as family violence, inequality in intimate relationships, a lack of financial resources and disempowering interactions with service providers. Although women were not directly asked about their experiences of abuse in this study, six participants disclosed childhood sexual abuse, five had experienced domestic violence, while seven women provided accounts of gender-based discrimination encountered in relationships. Women spoke of service providers from a range of professional backgrounds (e.g. doctors, midwives, infant health nurses, teachers, child protection staff) stripping them of their dignity and humanity through subjecting them to processes, language and actions that invalidated their own experiences and failed to recognise their individual characteristics or needs. Assessment tools were administered mechanically, devoid of a relational context, leading one woman to observe: I think sometimes they need to listen to the individual a bit more. Because the amount of times I’ve filled out the (Edinburgh PND scale) … and a lot of the time I find they just focus on that rather than the individual situation. I find that a little frustrating. Some women perceived higher levels of monitoring of their early parenting occurred because of stigma relating to their mental illness. They felt that this scrutiny was aimed at meeting the organisation’s risk management frameworks rather than supporting their mental health and the well-being of their child: … they ticked the boxes, (visiting me) 2 or 3 times instead of just the once, and that really annoyed me because I didn’t want them to come and visit me … they sit there with a questionnaire and go through it to tick their boxes, how did that actually help me? It didn’t help me, I just sat there feeling judged, and every time after they left I cried. Another participant pinpointed prejudice in practitioners as a factor that undermined the therapeutic relationship, stating that ‘they try to judge you straight away and they don’t even know you. I don’t like people like that’. Exasperation was expressed by a different participant with what she perceived as the unrelenting demands of child protection to demonstrate her mothering competence in the context of social isolation, cumulative trauma and poverty: ‘I’m sick of jumping through (service system) hoops. I’m over it. If they had just left me in the first place, I would have been OK.’ Patronising and demeaning responses from doctors were also related: I think there’s sexism involved, definitely … ‘there there, woman, you’re just worrying, you’re just a worried mother hen’. That’s what he (the doctor) said to me and I went off at that. No, my baby’s not eating and losing weight. Don’t tell me I’m a mother hen! Experiences of gender-based oppression were also apparent within intimate relationships. Seeing patriarchal economic and social relations mirrored all around them in their ‘close-knit’ ‘family-focused’ communities, women had difficulty in identifying and addressing inequality in their own relationships which contributed to their sense of powerlessness and dependence. Distribution of domestic labour was gendered for women who were partnered and, although they appeared to accept their household role, they simultaneously expressed a sense of injustice relating to their lack of freedom and autonomy. One woman claimed that her husband was supportive when she was unwell, in that he did not expect her to have domestic tasks completed by a set time. However, she later clarified that these tasks remained her sole responsibility to undertake. Another woman expressed conflicted thoughts: I would like him to do more around the house, but then I feel the guilt of me being there (and not in paid work, therefore), I should be doing much more of the housework than him … I love my children but I do feel that my life has changed much more than I thought it would. Financial stress was also an oppressive force for women reliant on government payments as their primary source of income. Five women had no independent transport and lived in public housing. They struggled to meet fundamental expenses such as food, clothing and education costs for their children. However, their resourcefulness and tenacity in managing these circumstances were apparent in the ways they used facilities like public libraries and community houses, sought out online forums for anonymous support, and developed reciprocal relationships with friends and neighbours to assist with childcare. Recovering from trauma, not mental illness Women most commonly spoke about recovering not from the symptoms or impact of their illness, but from the events or cumulative traumas that had precipitated the illness diagnosis. Participants in this study identified the mental illness symptoms they experienced as being a psychological response to manage extreme traumatic distress from past events. For some women, this distress emerged from physical, emotional or sexual abuse in childhood; for others, it was the result of a one-off event, such as physical injury, the death of a baby, a traumatic childbirth or the serious injury of a sibling. Narratives of severe distress in childhood that had resulted from abuse and neglect were forthcoming, without the need for specific questioning or prompting. One participant disassociated to manage pain from a pattern of maternal rejection and psychological bullying: ‘I really space out, it’s just a thing I do, a coping mechanism I’ve been told.’ Another participant experienced horrific trauma in her childhood resulting from physical and sexual assault. She described using drugs and alcohol, and enduring violent relationships in response to the ongoing state of distress she found herself in. Being ‘ripped away’ from her birth mother was how one woman described her early life. In her first weeks of life, she was placed with an adoptive family whom she depicted as caring and responsive, but ineffective in identifying or addressing her particular needs. She described perceptions that she was expected to conform to a set of values and behaviours to which she did not relate. This led to feelings of alienation and isolation that were later in adulthood labelled as symptomatic of borderline personality disorder: ‘There was a certain way you did something, and that wasn’t me. And now, for the first time in my life I’m starting to make my own decisions and not worry about what other people think.’ Episodes of maternal rejection or emotional abuse were portrayed by seven participants, with an additional two women sharing experiences of being physically abused by their fathers and this being witnessed and tolerated by their mothers. The most common reaction to the immediate distress arising from these encounters was emotional blunting and, for some women, this response continued into the present: I just thought, have you inbuilt it into me over the years that I just go blank and freeze and can’t think of anything when you look at me a certain way? … I couldn’t even think what it was I was going to tell her. I hate it. Making a change Participants identified turning points where an event or an insight led to them making deliberate choices around their behaviour that would lead to improved mental and physical well-being in the longer term. Four women spoke of this being partially instigated by the actions of intimate partners. In three cases, women left relationships following escalations of violence in which they perceived their lives to be in danger. In another instance, a controlling partner unexpectedly left the relationship abruptly and permanently. For three women, deciding to leave a culture of drug use which had served as a coping mechanism for years was a symbol of their raised consciousness about the numbing impact of drug use on their emotions and a reprioritising of their own health and their motherhood role. On ceasing drug use, one women related how she was able to see, for the first time, the damage her harsh responses were causing her children. With the aid of a supportive friend, she became aware of her children’s needs as independent from her own, and that these had to come above the demands of adult friends or family. Another woman claimed that, on ceasing marijuana use, she had begun to commit to … recovery full time … and giving up the drugs and even though it’s a crutch I suppose for a lot of stuff, it just took me that little bit longer to grasp it, to wear it, to own it and really to think about my life. This statement implies a conscious decision to take responsibility for past actions and future decisions. Another participant attributed acceptance of the need for self-care as being a critical contributing factor to her recovery. Although recognising her own capacity to care for others as being a stable and enduring component of her personal identity, it took recognition and conscious effort to value the effects of care for herself: ‘Self-care was something that I had never done particularly well so I had to start doing some of that. So making time for myself, and at first that felt quite selfish.’ Deciding to engage with services was one action women took to instigate change. Supportive service providers were described as non-judgemental, easy to talk to, practical, flexible and accessible. With supportive service providers, women felt safe to disclose openly their difficulties and challenges, and trusted that they would be listened to without prejudice. Having this support enabled women to begin to address the underlying issues associated with their mental illness and to commence building coping and parenting capacity. Communication skills were one of the core indicators that women used to ascertain whether a health professional was supportive, and thereby capable of assisting one to make a change. One participant identified the qualities she valued in her support worker as being ‘really good to talk to, I could talk to her about anything. But she puts her foot down and she sets the rules and the law, I really like the way she does it’. Feeling better In this healing phase, women gained strength and a belief in themselves that enabled them to reflect on their experiences, develop personal meaning regarding the mental illness, and identify and access resources to address their needs. For a number of women, social isolation and feeling ‘different’ to others in their family or community were significant barriers to recovery. Developing friendships or finding a community that shared some characteristic or experience helped to overcome isolation and assisted in rejecting narrow stereotypes and tolerating their ‘difference’. When feeling better, women were able to focus on attending to activities such as work or vocational training that would provide for themselves and their children into the future. Three participants spoke about coming to an acceptance of aspects of themselves that they had struggled with for years. This could be associated with receiving a formal diagnosis within the context of a supportive therapeutic relationship. One woman described how … the diagnosis has allowed me to not internalise as much, and realising that … because (I’ve) had all this trauma and abuse and whatever. No one’s going to be normal after that. So then I felt, I don’t know, validated I guess. Another woman felt more stable in her mental health and stronger in her identity after ‘coming out’ as same-sex-attracted. This woman shared the layers of discrimination she encountered in the rural context: If you’re not born and bred in this area you’re not a local. And then if you’re gay as well, oh my God! And then if you’re a single Mum, aw Jesus. And then if you’re a single, professional, gay Mum—oh my God! Can’t cope with that! For another participant, unplanned motherhood led initially to a severe exacerbation of her mental illness symptoms which lasted for almost two years. She described being completely incapacitated, with constant migraines, chronic anxiety and significant depression, requiring continual care from her parents. Despite her parents’ efforts to establish a routine that included exercise, relaxation, connecting her to her baby and self-care, eventually feeling better came about quite suddenly one day when her migraine disappeared and awareness resumed. At this point, she ‘still wasn’t 100% OK, it still took me a while to pick it up. But I’d say that is when I would have come home like a new Mum’. One component of feeling better was choosing to hope. This occurred when women were able to envisage a brighter future for themselves and their children, even if the present remained bleak: ‘You get to a point in life where you go, I can either be in self-destruction mode or I can garden and make it colourful, and that’s what I’ve done.’ Choosing hope was when women decided to embark on the arduous work described by one participant as ‘dragging yourself up’. Having children, even when they were removed from the mothers’ custody, provided motivation and a rationale for working towards recovery. Envisioning the children’s growth and development allowed women to imagine a future for themselves and their family. Aspiring to enjoy a ‘normal’ life, defined as one not dominated by illness, was voiced on multiple occasions. Women who had experienced inter-generational disadvantage, poverty and hardship hoped that, with their generation and through their actions and role modelling, cycles of trauma associated with substance use and sexual abuse would be broken. They hoped and believed that life would be easier for their children than it had been for them. Most of the women interviewed talked about hope in the context of wanting positive and healthy futures for their children. Acceptance of the hard times as well as the more positive days assisted women in coping with the relentless tasks of mothering. One woman conceded ‘every day is a good day, I have my bits of good and bits of shit’. In this context, personal recovery was unfamiliar as a realistic aspiration. Women who were dependent on government pensions and public housing spoke of hopes for what they deemed to be a ‘normal’ life. Encompassed within this were normative expectations around the economic resources that make for a satisfying life, such as reliable and accessible transport, occasional family holidays and the possibility of employment once children were old enough to attend school. Discussion Personal recovery and mothers While the concept of personal recovery is gaining momentum in Australia (Commonwealth of Australia, 2010), participants in this study did not employ the term ‘recovery’ to explain their experiences. Most did not see themselves as progressing in the key areas encapsulated within the definition of the concept (see introduction to this paper). Although participants expressed that they could imagine what the term might mean, they nevertheless felt as though the difficulties posed by their ongoing symptoms, financial hardship and parenting challenges persisted, creating barriers to engagement in life, gaining a sense of meaning and purpose, and developing a positive sense of self. Women expressed that they did not feel satisfied with their level of enjoyment or engagement in life and their sense of self was often overshadowed by negative interpretations of their deficits rather than abilities. In some cases, recovery may be a foreign and intangible term that feels incongruent with the daily struggles of enduring mental illness. This finding echoes a similar result articulated within a Canadian study (Morrow et al., 2011) where one participant spoke of ‘incorporating’ life experiences rather than recovering and ‘becoming’ as opposed to surviving. Elements of the CHIME framework were evident in the accounts women provided of their recovery journeys. Connectedness to family, friends and community was a significant facet of feeling better and was important in determining the success of attempts to seek support. Similarly to previous findings (Blegen et al., 2012), hope was difficult to sustain in the daily struggles of life, but crucial for providing motivation to persist. A positive identity was fostered through support for the mothering role and validation of women’s experiences, knowledge and skills. Empowerment resulted from respectful relationships (including with mental health services), learning to more effectively manage emotions and the accomplishment of new skills. Similarly to previous findings in studies with cohorts of mothers with mental illness, the mothering role was imbued with deep meaning (Carpenter-Song et al., 2014) and provided a socially validated purpose (Diaz-Caneja and Johnson, 2004; Chernomos et al., 2000; Montgomery et al., 2006). For the cohort of this study, feeling better and choosing to hope were where women had moved towards; however, most were still living in extremely difficult socio-economic circumstances that challenged their mental health on a daily basis. Factors such as the relentless burden of single parenting (Sands, 1995), financial hardship (Luciano et al., 2014; Nicholson et al., 1998; Ruepert and Maybery, 2007), lack of transport, conflictual relationships (Perera et al., 2014; Nicholson et al., 1998), histories of trauma (Perera et al., 2014; Nicholson et al., 2006), unemployment and lack of social support (Mowbray et al., 2003) and social connection had substantial impact. These issues were more profound for women who were single mothers. Likewise, child protection involvement was more common for these women and they were also more likely to have had past experiences of family violence or sexual assault. In this context, personal resources to foster recovery for single mothers with mental illness are likely to be scarce, while paradoxically more intensely required to overcome the cumulative traumas that have contributed to the mental illness. Women’s preference for describing their mental illness journey as managing, struggling or persisting, rather than recovering, may be indicative of the active parenting life phase they were in, caring for children who were the primary recipients of sparse family resources. Women may attain increased resources to direct towards their own needs once children become independent. Alternatively, women with experiences of serious and cumulative trauma that lead to enduring mental illness may find themselves in circumstances of such vulnerability and disadvantage such that, without sustained support, they are unable to obtain opportunities to gain the social and personal resources needed to recover. Trauma and change Personal recovery for the mothers in this study is perhaps better understood when two of the themes from interviews are combined. Managing distress and subsequently making a change provide important indicators of potential intervention points for social work practitioners. As found in previous research (Cutajar, 2010; Victorian Health Promotion Foundation, 2004), the majority of the women interviewed identified traumatic events in their lives that precipitated or accompanied their mental health problem. Many then recounted how experiences of the initial violence or abuse led to successive relationships that contained violence, oppression and substance misuse, intensifying mental illness symptoms. Therefore, the illness may actually be understood by women as the beginning of a process of healing, when they can no longer rely on their previous strategies for managing the distress caused by past or current trauma. Opportunities for intervention were identified by women as they described previous attempts to seek support; however, their encounters with service providers had resulted in an exacerbation of unequal power dynamics that left them feeling dehumanised and, in the most severe examples, re-traumatised. A common and significant window of opportunity appeared to be in the perinatal phase, when women desperately needed information, reassurance, support and referral. While the principals and practices of trauma-informed care are already being employed within mental health services (Muskett, 2014), this study suggests inadequate progress has been achieved on fully implementing this model across the range of health and community sectors that women with mental illness access. Due to the apparent salience of the perinatal period, trauma-informed care built on a strength-based foundation of practice would also be recommended for midwifery and early parenting services. Outcomes may have been enhanced through the development of trusting non-judgemental relationships with midwifery, maternal and child health and mental health professionals that took account of the women’s experiences, knowledge and skills, and promoted their agency and choice. Social work professionals are rarely employed within maternity or early-years education settings; however, numerous roles are apparent. These include providing training to midwives, nurses and educators on how to support parents with mental illness, offering secondary consultations, establishing early-intervention programmes and facilitating peer support groups, all of which could improve outcomes for mothers and prevent mental health difficulties in their offspring (Maybery et al., 2015). Research considerations This study was conducted with a small cohort of women who were mothers with mental illness, living in rural locations across Australia. Future research replicating this study with a metropolitan group of women is warranted. Women were not screened for their current wellness, and participants would be expected to articulate their views and experiences differently at different points in time, as recovery is ever-changing. One woman explicitly stated that, had she been unwell, her responses would have been considerably divergent. A strength of this study was the diversity in the cohort; however, a consideration is the ways in which single mothers (as opposed to those with supportive partners) and those women who had contact with mental health services compared to those who had not may have had vastly different experiences relating to issues like economic and housing security and fear of custody loss. Two of the participants identified being of Aboriginal descent, and there are particular historic, cultural and political factors that impact on Indigenous people that shape experiences around mothering and mental illness. However, there was insufficient information gathered to enable a separate analysis of this cohort. Investigation of the issues surrounding mental illness within the broader concept of social and emotional well-being, mothering and experiences of recovery and healing with Indigenous women is recommended. Implications for social work policy, practice and research This study adds to the understanding of the experiences of mothers with mental illness, specifically associated with personal recovery. One important implication for social work practice is that practitioners and services must work with women to identify and manage past traumas. As noted by Isobel (2016), in the psychiatric setting, Understanding the impact of trauma on individuals does not discount their current or future diagnosis, nor alter the course of their care, but rather contextualises them, their diagnosis, their behaviours and their experiences, while informing practice in a way that aids effective treatment and recovery (p. 590). The research also indicates a need to help identify key turning points offering opportunities to build supportive relationships that validate women’s experiences, increase their community connection and support their parenting functioning. The high rates of violence and sexual assault in this cohort are substantiated by national and international statistics (Australian Bureau of Statistics, 2012; Morrow, 2002; World Health Organisation, 2016) and often precipitate mental illness. These data indicate the need for additional resources to redress gender inequalities and cultural norms surrounding masculinity and femininity which are determinants of violence against women (Victorian Health Promotion Foundation, 2007; World Health Organisation, 2016). A need for mental health promotion and education to challenge stigma was also indicated, with a focus on early-years providers and workplaces. Social work policy on early-intervention and cross-sector collaboration needs to be extended to reflect the gaps in current service provision and capitalise on opportunities to have increased impact (Reupert et al., 2015). Future research is recommended with mothers who have adult children to ascertain whether personal recovery outcomes vary as children become more autonomous and women enter a new life phase. Research with midwifery and maternal and child health nurses identifying and addressing barriers and enablers to psycho-social aspects of early parenting for women with existing mental illness and how social work as a discipline can support this fundamental work is also recommended. Conclusion Recovery outcomes may not be articulated as women’s primary goal and may not appear relevant or even possible during early parenting. Social workers employed within mental health services need to embrace and transmit a strength-based, trauma-informed approach that is informed by a gendered framework that differentiates the needs and experiences of women who are mothers. For many women, it is equally important to focus upon the prior experience of trauma rather than focus on the mental illness. Validating women’s knowledge, roles and experiences is fundamental to establishing the trusting and respectful relationship that is required to address both mental health and parenting needs. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

Resourcefulness and Resilience: The Experience of Personal Recovery for Mothers with a Mental Illness

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
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0045-3102
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1468-263X
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10.1093/bjsw/bcx099
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Abstract

Abstract Understanding of key characteristics and processes of personal recovery from mental illness is growing. However, a paucity of research exists with mothers with mental illness around experiences of personal recovery. An improved understanding of the interplay between illness, parenting and broader social factors may better inform how mental health services respond to the needs of these women. Using constructivist grounded theory (CGT), in-depth interviews were conducted with seventeen women who were mothers with a mental illness, residing in Australia. Through the CGT technique of constant comparative analysis, initial codes were synthesised and theoretical sampling employed to reach saturation of the categories associated with the construct of personal recovery. For mothers with a mental illness, personal recovery takes place within and is shaped by broader social contexts. Six key dimensions of personal recovery were ‘recognising recovery’, ‘mothering’, ‘experiencing oppression’, ‘managing distress’, ‘making a change’ and ‘feeling better’. This study found that mothers with mental illness interpret recovery as enduring through difficult times, rather than a process of personal transformation and adjustment which is articulated within personal recovery literature. Well-being outcomes for women with children may be more effectively promoted through strategies that address underlying factors such as supporting early mothering, preventing violence against women, addressing trauma, and redressing socio-economic disadvantage and gender disparity. Personal recovery, mental health, mothering, trauma-informed care Introduction Personal recovery As part of multidisciplinary teams, social workers are advantageously positioned within mental health services to be able to promote recovery from mental illness. Social workers are also employed across a range of family settings including early years, child protection, drug and alcohol services, and community health, where they may encounter maternal mental health difficulties. As mental health services re-orientate towards a personal recovery focus (Wyder and Bland, 2014), social work training prepares practitioners to respond with family-focused practice (Maybery et al., 2014), community development approaches (Forde and Lynch, 2015) and understanding of socio-economic and political enablers and barriers to recovery (Bowen and Walton, 2015). Recovery is broader and more complex than narrow medical constructions (Deegan, 1996; Slade, 2009) and defined to include living ‘a satisfying, hopeful and contributing life’ (Anthony, 1993, p. 13), developing ‘a sense of integrity and purpose’ (Deegan, 1988, p. 15) and building ‘connection, safety, hope, and acknowledgment of (one’s) spiritual self’ (Long, 1994, p. 4). Implicit is that recovery can occur even when psychiatric symptoms persist. Built upon thirty years of momentum, personal recovery is now the guiding principal underpinning the Australian national mental health services policy and practice (Commonwealth of Australia, 2010, 2013). Equally, in 2012, trauma-informed care practice guidelines were developed for universal implementation across settings, in recognition of the high prevalence and profound implications of trauma on individuals with mental illness and their families (Kezelman and Stavropoulos, 2012). The conceptual basis of personal recovery was recently strengthened by the undertaking of a systematic review of eighty-seven articles exploring personal recovery and mental illness (Shanks et al., 2013). Connectedness, Hope and optimism, Identity, Meaning in life and Empowerment were confirmed as key principles underpinning the recovery concept (Leamy et al., 2011). While validating a CHIME framework, the review illustrated that personal recovery is rarely viewed from a mother’s perspective. Parenting with a mental illness is not mentioned in the review of the eighty-seven studies. Mothering with mental illness Only 16 per cent of Australian women remain childless into their forties (Australian Bureau of Statistics, 2008) and it has been observed that ‘motherhood, which is often an intensive and lifelong relationship for women, can have a significant impact on women’s identities’ (Laney et al., 2015, p. 127). It is estimated that over 50 per cent of women with mental illness are parents (Maybery et al., 2009; Parker et al., 2008) and recognised that the challenges of parenting can impact on mental health (Ackerson, 2003), while mental illness symptoms, treatment and associated difficulties can compromise parenting capacity (Montgomery et al., 2006; Venkataraman and Ackerson, 2008) and impact on all family members (Reupert and Maybery, 2007). However, parenting is rarely alluded to in personal recovery discourse (Nicholson, 2014). Conceptually, personal recovery has been about individuals, with carers of those in recovery receiving occasional mention (Wyder and Bland, 2014). Rarely is the perspective of mothers with mental illness caring for children included in personal recovery discourse. Mothering is highly gendered (Chodorow, 1978), socially and culturally constructed (Hays, 1996) and at times difficult and demanding (Hays, 1996; Ussher, 1991). Women with a mental illness face additional parenting challenges, including symptoms and treatment (Ackerson, 2003), socio-economic disadvantage (Luciano et al., 2014), difficult family relationships (Perera et al., 2014), and community stigma (Seeman, 2010) and discrimination from health service providers (Cremers et al., 2014). These latter issues at times result in women’s recovery being compromised due to masking symptoms when they are unwell, to reduce the risk of separation from their children through custody loss (Montgomery et al., 2006; Venkataraman and Ackerson, 2008). However, the experiences and needs of mothers with mental illness require greater understanding. This study examines the experience personal recovery from mental illness from the perspective of rural women who are also parents. The study investigates the characteristics and processes that rural mothers found to be significant in their recovery journey, including the factors that facilitate or impede recovery. Rural women were selected as participants as they are under-represented in studies exploring the impact of mental illness and it was considered that their needs and experiences may differ due to their rural location. Methods Following ethics approval from two health service and one university Human Research Ethics Committees, women were informed of the study via mental health clinicians and social and print media. Women were screened for eligibility (one child aged under eighteen years in their care at least 50 per cent or the time, self-identified psychiatric diagnosis and living rurally) and participants gave written informed consent. Ten (of seventeen) participants had current or past involvement with a mental health service and their backgrounds are illustrated below. Interviews (three by phone and seventeen face to face) were audio recorded and transcribed verbatim and conducted by the first author. The flexible interview schedule asked mothers about their perspectives and experiences of their illness, motherhood and their personal recovery. Examples of open-ended questions included: Tell me about your mental health difficulties. What does recovery mean to you? How has becoming a mother changed the way you see yourself? Data were analysed concurrently with data collection using a constructivist grounded theory (CGT) approach (Charmaz, 2014), initially through line-by-line coding whereby every line of data was coded with a gerund that described the social or psychological process occurring. Focused coding was then undertaken, facilitated by memo writing and mind mapping (Charmaz, 2014). During this process, those codes with ‘more theoretical reach, direction and centrality’ (Charmaz, 2014, p. 141) were raised to categories. The properties of those categories including the circumstances under which they transpired were explored. Emerging ideas about relationships between codes and categories were represented pictorially (Figure 1). Figure 1 View largeDownload slide Personal recovery conceptual map Methods: This conceptual map was developed as a visual representation of the data analysis following the conducting of in-depth qualitative interviews with seventeen women who were mothers with mental illness, residing in rural locations. Employing constructivist grounded theory methods (Charmaz, 2014), constant comparative analysis commenced with line-by-line coding, followed by focused coding facilitated by memo writing and mind maps. Results: The circles connected by arrows within the map represent the categories that describe the process of personal recovery: managing distress, making a change and feeling better. The words and phrases within these circles define the properties of the category. The arrows between the circles describe the possible routes within the journey. The outer sphere encompasses the social and societal environment within which personal recovery takes place. Prominent in this is the experience of mothering, rural settings and cultures, and the experience of oppression related to the mental illness, poverty and disadvantage, gender inequity and/or social isolation. Figure 1 View largeDownload slide Personal recovery conceptual map Methods: This conceptual map was developed as a visual representation of the data analysis following the conducting of in-depth qualitative interviews with seventeen women who were mothers with mental illness, residing in rural locations. Employing constructivist grounded theory methods (Charmaz, 2014), constant comparative analysis commenced with line-by-line coding, followed by focused coding facilitated by memo writing and mind maps. Results: The circles connected by arrows within the map represent the categories that describe the process of personal recovery: managing distress, making a change and feeling better. The words and phrases within these circles define the properties of the category. The arrows between the circles describe the possible routes within the journey. The outer sphere encompasses the social and societal environment within which personal recovery takes place. Prominent in this is the experience of mothering, rural settings and cultures, and the experience of oppression related to the mental illness, poverty and disadvantage, gender inequity and/or social isolation. As per the CGT methodology (Charmaz, 2014), following the tenth interview, theoretical sampling techniques were undertaken to further examine ambiguous or incomplete elements within the emerging data. An additional ten interviews were conducted (three being second interviews with existing participants, seven with new participants) with a revised interview schedule to explore further the meaning and processes of personal recovery. As codes emerged, the researcher purposefully recruited to the study participants who had characteristics that enabled them to provide additional data that deepened understanding of the properties of the emerging codes (and subsequently the categories). This is consistent with CGT methodology, and multiple interviews with the same participants is a common process as the data analysis process is both emergent and inductive (Charmaz, 2014). New data are compared with previously gathered data, which may result in fresh insights or the highlighting of a code as significant, warranting further exploration in relation to its meaning and the circumstances under which it occurs. Components of the data were coded by two researchers. Discussion between all three authors enabled consolidation of categories and promoted reflexivity. Participants Twenty interviews were held with seventeen women. Women were aged between twenty-three and fifty-three years, and had an average age of 36.29 (SD = 8.27). Cultural background was described as Australian for ten participants, Australian/English for two and Australian/German for one woman. Two women identified as having Aboriginal heritage, while an additional woman identified as part of the Aboriginal community through being a mother to Aboriginal children. The remaining participant stated that her biological parents were Italian and Finnish, although she had grown up in an adoptive Australian family. Self-reported diagnoses included bipolar disorder (five), borderline personality disorder (two), anxiety (nine), psychosis (two), depression (eleven), post-natal depression (four) and obsessive compulsive disorder (two). Fourteen women reported having two or more diagnoses. Participants had a total of thirty-seven children, averaging 2.18 children per family. The average age of children was 8.27, with a range from six months to seventeen years. Eight of those children were living in out-of-home care at the time of the interview; however, all but one women had at least one dependent child living with them. Eight participants relied on a government payment as their primary source of income, while two were employed full time, four were supported by a combination of their partner’s wages and their own part-time wages, and two derived an income from the family farm. The majority (n = 9) of women lived with their partner and children, four lived with their children only, one lived alone and two lived with their child and their parents. Nine of the women owned or were buying their home, five lived in private rental and three lived in public housing, one of these being transitional housing. Findings The following sections detail the categories emerging from the data relating to personal recovery. Recognising recovery Of the seventeen women interviewed, seven were familiar with the term ‘personal recovery’ at the outset of the interview. Those who were familiar had all had a long-term relationship with a psychiatric rehabilitation service (which in Australia is a community-based organisation which promotes psycho-social recovery and rehabilitation) instead of or in addition to a clinical mental health service (which is more likely to be focused on promoting clinical recovery through medical and psychological therapies). One woman who strongly related to the term stated: Recovery to me … is seeing myself beyond the illness. It’s about moving forward in life. It’s about getting back into study, it’s about educating yourself and wearing the illness so that you know you can walk through any door and you know that you’re unique inside, that you’ve got it in yourself, you can help someone else. All participants, regardless of their familiarity with ‘personal recovery’ in mental illness, were able to conceptualise how it might be relevant for them. Concepts associated with recovery included acceptance, normalcy, validation, emotion regulation, personal insight, gaining understanding, seeking support and making conscious changes. Acceptance was multifaceted and included acknowledgement of an underlying problem, a diagnosis, the need to take medication, the need to access services and supports, and acceptance of personal responsibility for initiating change. Being diagnosed and prescribed the correct medication are more closely aligned with clinical recovery outcomes; however, one woman described significantly improved cognitive function on commencing medication: When I used to think, it was like a freeway, like a fifty lane freeway of thought … all just going at once, and I can’t stop it, I can’t help it. It frustrates me … but with the tablets I am able to just slow it down. I can pick one, and I can have it slowed down even more, and I can concentrate on that line. It makes things a lot clearer, which makes it better. Recovery was described as a process that is unique, individual, ongoing and active, requiring conscious effort and commitment: ‘… recovery, can start with a beginning … a realisation that there is something wrong, really wrong, I need to help myself.’ One participant regarded recovery as impossible for her, seeing her symptoms as ongoing and persistent barriers to achieving 100 per cent clinical recovery, thereby dismissing other measures of recovery. She also commented that she regarded herself as a ‘normal’ mother, undertaking the same tasks as other mothers with equivalent competence, highlighting that mothering competence and confidence can occur while mental illness persists. Women related less to the concept of personal recovery than to the notion of enduring through continuing episodes of mental illness. Along the way and through personal reflection, they learned more about themselves and the factors that were likely to place stress upon them. They also developed skills to deflect the negative responses of others and resourcefully sought more helpful sources of support, whether that be via online forums, through health services or through developing friendships with like-minded peers. Through hearing the experiences of others, women learned to be less self-critical and to increase self-care activities that they had found to be effective: There’s just a lot of healing these days where I just don’t want to get up but I do. With my boy, he’s got school and I get up with him …. And if I go back and lie on the couch and sleep for an hour when he’s gone, sometimes I do that, I need that. Mothering The mothering role was dominant in women’s lives, and they spoke of their love and devotion to their children, in tandem with the values they wished to impart, such as independence, kindness, respect and a strong work ethic. However, for women with limited social and financial resources, the relentless labour of parenting was also apparent, and participants shared their struggles in attempting to provide for their children’s needs, aware that this left them depleted in time, energy, finances and other resources. Women articulated an understanding of the cultural expectations surrounding mothering, and aspired to meet them, conceding that their own needs were on hold until the children grew older because ‘that’s what being a mother is about—the kids’. While half of the women spoke of their desire for closer peer relationships with other mothers, their attempts at connection in settings such as new mothers groups often left them feeling as though they did not ‘fit in’ and ‘this divide or wedge got bigger and bigger’ due to differences in socio-economic status, cultural background, language or age. The demands of mothering influenced opportunities to source resources to promote recovery. However, recovery outcomes were also seen to benefit children, as women sensed that their wellness would provide security and hope for their children. Their hopes around the future were centred on being able to manage emotions, symptoms and challenges, with their mental illness diminishing in influence. Women aspired to enjoy more happiness and ‘just a bit of freedom’ rather than being overwhelmed by anxiety, sadness or confusion, ‘so when the kids come home they can see me on fire and they can see Mum leading a whole healthy life and not tortured by the past’. Experiencing oppression The social context of participants’ lives was found to be highly influential for promoting or hindering access to the personal, social and economic resources required to promote recovery from the mental illness and its effects. Oppression took many forms. The most profound was gender-based and manifested as family violence, inequality in intimate relationships, a lack of financial resources and disempowering interactions with service providers. Although women were not directly asked about their experiences of abuse in this study, six participants disclosed childhood sexual abuse, five had experienced domestic violence, while seven women provided accounts of gender-based discrimination encountered in relationships. Women spoke of service providers from a range of professional backgrounds (e.g. doctors, midwives, infant health nurses, teachers, child protection staff) stripping them of their dignity and humanity through subjecting them to processes, language and actions that invalidated their own experiences and failed to recognise their individual characteristics or needs. Assessment tools were administered mechanically, devoid of a relational context, leading one woman to observe: I think sometimes they need to listen to the individual a bit more. Because the amount of times I’ve filled out the (Edinburgh PND scale) … and a lot of the time I find they just focus on that rather than the individual situation. I find that a little frustrating. Some women perceived higher levels of monitoring of their early parenting occurred because of stigma relating to their mental illness. They felt that this scrutiny was aimed at meeting the organisation’s risk management frameworks rather than supporting their mental health and the well-being of their child: … they ticked the boxes, (visiting me) 2 or 3 times instead of just the once, and that really annoyed me because I didn’t want them to come and visit me … they sit there with a questionnaire and go through it to tick their boxes, how did that actually help me? It didn’t help me, I just sat there feeling judged, and every time after they left I cried. Another participant pinpointed prejudice in practitioners as a factor that undermined the therapeutic relationship, stating that ‘they try to judge you straight away and they don’t even know you. I don’t like people like that’. Exasperation was expressed by a different participant with what she perceived as the unrelenting demands of child protection to demonstrate her mothering competence in the context of social isolation, cumulative trauma and poverty: ‘I’m sick of jumping through (service system) hoops. I’m over it. If they had just left me in the first place, I would have been OK.’ Patronising and demeaning responses from doctors were also related: I think there’s sexism involved, definitely … ‘there there, woman, you’re just worrying, you’re just a worried mother hen’. That’s what he (the doctor) said to me and I went off at that. No, my baby’s not eating and losing weight. Don’t tell me I’m a mother hen! Experiences of gender-based oppression were also apparent within intimate relationships. Seeing patriarchal economic and social relations mirrored all around them in their ‘close-knit’ ‘family-focused’ communities, women had difficulty in identifying and addressing inequality in their own relationships which contributed to their sense of powerlessness and dependence. Distribution of domestic labour was gendered for women who were partnered and, although they appeared to accept their household role, they simultaneously expressed a sense of injustice relating to their lack of freedom and autonomy. One woman claimed that her husband was supportive when she was unwell, in that he did not expect her to have domestic tasks completed by a set time. However, she later clarified that these tasks remained her sole responsibility to undertake. Another woman expressed conflicted thoughts: I would like him to do more around the house, but then I feel the guilt of me being there (and not in paid work, therefore), I should be doing much more of the housework than him … I love my children but I do feel that my life has changed much more than I thought it would. Financial stress was also an oppressive force for women reliant on government payments as their primary source of income. Five women had no independent transport and lived in public housing. They struggled to meet fundamental expenses such as food, clothing and education costs for their children. However, their resourcefulness and tenacity in managing these circumstances were apparent in the ways they used facilities like public libraries and community houses, sought out online forums for anonymous support, and developed reciprocal relationships with friends and neighbours to assist with childcare. Recovering from trauma, not mental illness Women most commonly spoke about recovering not from the symptoms or impact of their illness, but from the events or cumulative traumas that had precipitated the illness diagnosis. Participants in this study identified the mental illness symptoms they experienced as being a psychological response to manage extreme traumatic distress from past events. For some women, this distress emerged from physical, emotional or sexual abuse in childhood; for others, it was the result of a one-off event, such as physical injury, the death of a baby, a traumatic childbirth or the serious injury of a sibling. Narratives of severe distress in childhood that had resulted from abuse and neglect were forthcoming, without the need for specific questioning or prompting. One participant disassociated to manage pain from a pattern of maternal rejection and psychological bullying: ‘I really space out, it’s just a thing I do, a coping mechanism I’ve been told.’ Another participant experienced horrific trauma in her childhood resulting from physical and sexual assault. She described using drugs and alcohol, and enduring violent relationships in response to the ongoing state of distress she found herself in. Being ‘ripped away’ from her birth mother was how one woman described her early life. In her first weeks of life, she was placed with an adoptive family whom she depicted as caring and responsive, but ineffective in identifying or addressing her particular needs. She described perceptions that she was expected to conform to a set of values and behaviours to which she did not relate. This led to feelings of alienation and isolation that were later in adulthood labelled as symptomatic of borderline personality disorder: ‘There was a certain way you did something, and that wasn’t me. And now, for the first time in my life I’m starting to make my own decisions and not worry about what other people think.’ Episodes of maternal rejection or emotional abuse were portrayed by seven participants, with an additional two women sharing experiences of being physically abused by their fathers and this being witnessed and tolerated by their mothers. The most common reaction to the immediate distress arising from these encounters was emotional blunting and, for some women, this response continued into the present: I just thought, have you inbuilt it into me over the years that I just go blank and freeze and can’t think of anything when you look at me a certain way? … I couldn’t even think what it was I was going to tell her. I hate it. Making a change Participants identified turning points where an event or an insight led to them making deliberate choices around their behaviour that would lead to improved mental and physical well-being in the longer term. Four women spoke of this being partially instigated by the actions of intimate partners. In three cases, women left relationships following escalations of violence in which they perceived their lives to be in danger. In another instance, a controlling partner unexpectedly left the relationship abruptly and permanently. For three women, deciding to leave a culture of drug use which had served as a coping mechanism for years was a symbol of their raised consciousness about the numbing impact of drug use on their emotions and a reprioritising of their own health and their motherhood role. On ceasing drug use, one women related how she was able to see, for the first time, the damage her harsh responses were causing her children. With the aid of a supportive friend, she became aware of her children’s needs as independent from her own, and that these had to come above the demands of adult friends or family. Another woman claimed that, on ceasing marijuana use, she had begun to commit to … recovery full time … and giving up the drugs and even though it’s a crutch I suppose for a lot of stuff, it just took me that little bit longer to grasp it, to wear it, to own it and really to think about my life. This statement implies a conscious decision to take responsibility for past actions and future decisions. Another participant attributed acceptance of the need for self-care as being a critical contributing factor to her recovery. Although recognising her own capacity to care for others as being a stable and enduring component of her personal identity, it took recognition and conscious effort to value the effects of care for herself: ‘Self-care was something that I had never done particularly well so I had to start doing some of that. So making time for myself, and at first that felt quite selfish.’ Deciding to engage with services was one action women took to instigate change. Supportive service providers were described as non-judgemental, easy to talk to, practical, flexible and accessible. With supportive service providers, women felt safe to disclose openly their difficulties and challenges, and trusted that they would be listened to without prejudice. Having this support enabled women to begin to address the underlying issues associated with their mental illness and to commence building coping and parenting capacity. Communication skills were one of the core indicators that women used to ascertain whether a health professional was supportive, and thereby capable of assisting one to make a change. One participant identified the qualities she valued in her support worker as being ‘really good to talk to, I could talk to her about anything. But she puts her foot down and she sets the rules and the law, I really like the way she does it’. Feeling better In this healing phase, women gained strength and a belief in themselves that enabled them to reflect on their experiences, develop personal meaning regarding the mental illness, and identify and access resources to address their needs. For a number of women, social isolation and feeling ‘different’ to others in their family or community were significant barriers to recovery. Developing friendships or finding a community that shared some characteristic or experience helped to overcome isolation and assisted in rejecting narrow stereotypes and tolerating their ‘difference’. When feeling better, women were able to focus on attending to activities such as work or vocational training that would provide for themselves and their children into the future. Three participants spoke about coming to an acceptance of aspects of themselves that they had struggled with for years. This could be associated with receiving a formal diagnosis within the context of a supportive therapeutic relationship. One woman described how … the diagnosis has allowed me to not internalise as much, and realising that … because (I’ve) had all this trauma and abuse and whatever. No one’s going to be normal after that. So then I felt, I don’t know, validated I guess. Another woman felt more stable in her mental health and stronger in her identity after ‘coming out’ as same-sex-attracted. This woman shared the layers of discrimination she encountered in the rural context: If you’re not born and bred in this area you’re not a local. And then if you’re gay as well, oh my God! And then if you’re a single Mum, aw Jesus. And then if you’re a single, professional, gay Mum—oh my God! Can’t cope with that! For another participant, unplanned motherhood led initially to a severe exacerbation of her mental illness symptoms which lasted for almost two years. She described being completely incapacitated, with constant migraines, chronic anxiety and significant depression, requiring continual care from her parents. Despite her parents’ efforts to establish a routine that included exercise, relaxation, connecting her to her baby and self-care, eventually feeling better came about quite suddenly one day when her migraine disappeared and awareness resumed. At this point, she ‘still wasn’t 100% OK, it still took me a while to pick it up. But I’d say that is when I would have come home like a new Mum’. One component of feeling better was choosing to hope. This occurred when women were able to envisage a brighter future for themselves and their children, even if the present remained bleak: ‘You get to a point in life where you go, I can either be in self-destruction mode or I can garden and make it colourful, and that’s what I’ve done.’ Choosing hope was when women decided to embark on the arduous work described by one participant as ‘dragging yourself up’. Having children, even when they were removed from the mothers’ custody, provided motivation and a rationale for working towards recovery. Envisioning the children’s growth and development allowed women to imagine a future for themselves and their family. Aspiring to enjoy a ‘normal’ life, defined as one not dominated by illness, was voiced on multiple occasions. Women who had experienced inter-generational disadvantage, poverty and hardship hoped that, with their generation and through their actions and role modelling, cycles of trauma associated with substance use and sexual abuse would be broken. They hoped and believed that life would be easier for their children than it had been for them. Most of the women interviewed talked about hope in the context of wanting positive and healthy futures for their children. Acceptance of the hard times as well as the more positive days assisted women in coping with the relentless tasks of mothering. One woman conceded ‘every day is a good day, I have my bits of good and bits of shit’. In this context, personal recovery was unfamiliar as a realistic aspiration. Women who were dependent on government pensions and public housing spoke of hopes for what they deemed to be a ‘normal’ life. Encompassed within this were normative expectations around the economic resources that make for a satisfying life, such as reliable and accessible transport, occasional family holidays and the possibility of employment once children were old enough to attend school. Discussion Personal recovery and mothers While the concept of personal recovery is gaining momentum in Australia (Commonwealth of Australia, 2010), participants in this study did not employ the term ‘recovery’ to explain their experiences. Most did not see themselves as progressing in the key areas encapsulated within the definition of the concept (see introduction to this paper). Although participants expressed that they could imagine what the term might mean, they nevertheless felt as though the difficulties posed by their ongoing symptoms, financial hardship and parenting challenges persisted, creating barriers to engagement in life, gaining a sense of meaning and purpose, and developing a positive sense of self. Women expressed that they did not feel satisfied with their level of enjoyment or engagement in life and their sense of self was often overshadowed by negative interpretations of their deficits rather than abilities. In some cases, recovery may be a foreign and intangible term that feels incongruent with the daily struggles of enduring mental illness. This finding echoes a similar result articulated within a Canadian study (Morrow et al., 2011) where one participant spoke of ‘incorporating’ life experiences rather than recovering and ‘becoming’ as opposed to surviving. Elements of the CHIME framework were evident in the accounts women provided of their recovery journeys. Connectedness to family, friends and community was a significant facet of feeling better and was important in determining the success of attempts to seek support. Similarly to previous findings (Blegen et al., 2012), hope was difficult to sustain in the daily struggles of life, but crucial for providing motivation to persist. A positive identity was fostered through support for the mothering role and validation of women’s experiences, knowledge and skills. Empowerment resulted from respectful relationships (including with mental health services), learning to more effectively manage emotions and the accomplishment of new skills. Similarly to previous findings in studies with cohorts of mothers with mental illness, the mothering role was imbued with deep meaning (Carpenter-Song et al., 2014) and provided a socially validated purpose (Diaz-Caneja and Johnson, 2004; Chernomos et al., 2000; Montgomery et al., 2006). For the cohort of this study, feeling better and choosing to hope were where women had moved towards; however, most were still living in extremely difficult socio-economic circumstances that challenged their mental health on a daily basis. Factors such as the relentless burden of single parenting (Sands, 1995), financial hardship (Luciano et al., 2014; Nicholson et al., 1998; Ruepert and Maybery, 2007), lack of transport, conflictual relationships (Perera et al., 2014; Nicholson et al., 1998), histories of trauma (Perera et al., 2014; Nicholson et al., 2006), unemployment and lack of social support (Mowbray et al., 2003) and social connection had substantial impact. These issues were more profound for women who were single mothers. Likewise, child protection involvement was more common for these women and they were also more likely to have had past experiences of family violence or sexual assault. In this context, personal resources to foster recovery for single mothers with mental illness are likely to be scarce, while paradoxically more intensely required to overcome the cumulative traumas that have contributed to the mental illness. Women’s preference for describing their mental illness journey as managing, struggling or persisting, rather than recovering, may be indicative of the active parenting life phase they were in, caring for children who were the primary recipients of sparse family resources. Women may attain increased resources to direct towards their own needs once children become independent. Alternatively, women with experiences of serious and cumulative trauma that lead to enduring mental illness may find themselves in circumstances of such vulnerability and disadvantage such that, without sustained support, they are unable to obtain opportunities to gain the social and personal resources needed to recover. Trauma and change Personal recovery for the mothers in this study is perhaps better understood when two of the themes from interviews are combined. Managing distress and subsequently making a change provide important indicators of potential intervention points for social work practitioners. As found in previous research (Cutajar, 2010; Victorian Health Promotion Foundation, 2004), the majority of the women interviewed identified traumatic events in their lives that precipitated or accompanied their mental health problem. Many then recounted how experiences of the initial violence or abuse led to successive relationships that contained violence, oppression and substance misuse, intensifying mental illness symptoms. Therefore, the illness may actually be understood by women as the beginning of a process of healing, when they can no longer rely on their previous strategies for managing the distress caused by past or current trauma. Opportunities for intervention were identified by women as they described previous attempts to seek support; however, their encounters with service providers had resulted in an exacerbation of unequal power dynamics that left them feeling dehumanised and, in the most severe examples, re-traumatised. A common and significant window of opportunity appeared to be in the perinatal phase, when women desperately needed information, reassurance, support and referral. While the principals and practices of trauma-informed care are already being employed within mental health services (Muskett, 2014), this study suggests inadequate progress has been achieved on fully implementing this model across the range of health and community sectors that women with mental illness access. Due to the apparent salience of the perinatal period, trauma-informed care built on a strength-based foundation of practice would also be recommended for midwifery and early parenting services. Outcomes may have been enhanced through the development of trusting non-judgemental relationships with midwifery, maternal and child health and mental health professionals that took account of the women’s experiences, knowledge and skills, and promoted their agency and choice. Social work professionals are rarely employed within maternity or early-years education settings; however, numerous roles are apparent. These include providing training to midwives, nurses and educators on how to support parents with mental illness, offering secondary consultations, establishing early-intervention programmes and facilitating peer support groups, all of which could improve outcomes for mothers and prevent mental health difficulties in their offspring (Maybery et al., 2015). Research considerations This study was conducted with a small cohort of women who were mothers with mental illness, living in rural locations across Australia. Future research replicating this study with a metropolitan group of women is warranted. Women were not screened for their current wellness, and participants would be expected to articulate their views and experiences differently at different points in time, as recovery is ever-changing. One woman explicitly stated that, had she been unwell, her responses would have been considerably divergent. A strength of this study was the diversity in the cohort; however, a consideration is the ways in which single mothers (as opposed to those with supportive partners) and those women who had contact with mental health services compared to those who had not may have had vastly different experiences relating to issues like economic and housing security and fear of custody loss. Two of the participants identified being of Aboriginal descent, and there are particular historic, cultural and political factors that impact on Indigenous people that shape experiences around mothering and mental illness. However, there was insufficient information gathered to enable a separate analysis of this cohort. Investigation of the issues surrounding mental illness within the broader concept of social and emotional well-being, mothering and experiences of recovery and healing with Indigenous women is recommended. Implications for social work policy, practice and research This study adds to the understanding of the experiences of mothers with mental illness, specifically associated with personal recovery. One important implication for social work practice is that practitioners and services must work with women to identify and manage past traumas. As noted by Isobel (2016), in the psychiatric setting, Understanding the impact of trauma on individuals does not discount their current or future diagnosis, nor alter the course of their care, but rather contextualises them, their diagnosis, their behaviours and their experiences, while informing practice in a way that aids effective treatment and recovery (p. 590). The research also indicates a need to help identify key turning points offering opportunities to build supportive relationships that validate women’s experiences, increase their community connection and support their parenting functioning. The high rates of violence and sexual assault in this cohort are substantiated by national and international statistics (Australian Bureau of Statistics, 2012; Morrow, 2002; World Health Organisation, 2016) and often precipitate mental illness. These data indicate the need for additional resources to redress gender inequalities and cultural norms surrounding masculinity and femininity which are determinants of violence against women (Victorian Health Promotion Foundation, 2007; World Health Organisation, 2016). A need for mental health promotion and education to challenge stigma was also indicated, with a focus on early-years providers and workplaces. Social work policy on early-intervention and cross-sector collaboration needs to be extended to reflect the gaps in current service provision and capitalise on opportunities to have increased impact (Reupert et al., 2015). Future research is recommended with mothers who have adult children to ascertain whether personal recovery outcomes vary as children become more autonomous and women enter a new life phase. Research with midwifery and maternal and child health nurses identifying and addressing barriers and enablers to psycho-social aspects of early parenting for women with existing mental illness and how social work as a discipline can support this fundamental work is also recommended. Conclusion Recovery outcomes may not be articulated as women’s primary goal and may not appear relevant or even possible during early parenting. Social workers employed within mental health services need to embrace and transmit a strength-based, trauma-informed approach that is informed by a gendered framework that differentiates the needs and experiences of women who are mothers. For many women, it is equally important to focus upon the prior experience of trauma rather than focus on the mental illness. Validating women’s knowledge, roles and experiences is fundamental to establishing the trusting and respectful relationship that is required to address both mental health and parenting needs. 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The British Journal of Social WorkOxford University Press

Published: Jul 1, 2018

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