AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Creating Possibilities: Working Together
Anna Clarke, Youth & Parent Services, Adelaide Central Mission
Introduction
Background
The Referral
Collaboration
Ongoing Therapy
Helen
Conclusions/Recommendations
References/Acknowledgements
This paper will explore the issues of depression and isolation for a young woman (Helen) and her family who are living in a remote area. It will focus on how we as an agency used technology and collaborative partnerships as a tool and a creative way of overcoming the issues of isolation. That being flexible and excited by working in new and innovative ways can provide a service for families where they can experience positive outcomes. This will be demonstrated via the case study of Helen when she was suicidal and diagnosed with depression. It will explore how the therapeutic relationship was built using a mixture of face to face counselling, tele-conferencing, narrative ideas, Ruby's and working collaboratively with the Adelaide Womens & Children's Hospital, Hospital Links, CAMHS, the Education Department and Adolescent Services Enfield Campus. All of these gave a greater sense of community, support networks and possibilities with which they could re-connect with their strengths, their uniqueness, each other and a much broader knowledge of their ideas about what works, what doesn't and what is needed in the future.
'IT IS AN EXPLOSION OF BRIGHT COLOURS, OF HELEN, SNEAKING THROUGH THE BLACK SHELL THAT TRAPPED ME' (Helen 2000)
This story and paper is being presented not only with the family's permission but with their collaboration, input and personal insights in the hope that we may be able to look more closely to the way in which we provide a service and to the responsibility we hold in being accountable to the work that we do with the families that we consult with. I am presenting this paper not just from a client focused perspective as it is much more than that. Although I am presenting some ideas around the way in which I did this work and give some insight into how I came about my conclusions you will very much hear the voice of the family, their names and where they live has not been changed with the view to the telling of their real story and about change, not only for them, but for us.
I would very much like to thank John and Helen for their willingness to share their story with so many people in such an honest and trusting way and for being co-authors to this paper.
YOUTH & PARENT SERVICES - (YPS) YPS counselling works with families and young people where there is a risk of the young person not remaining at home, where there is family conflict and with the many various issues that families face. Ruby's is the accommodation service of YPS and works from a therapeutic context in conjunction with counselling. The two together provide a framework in which change becomes possible within a challenging yet nurturing environment.
HELEN - Helen is artistic, she produces the most beautiful paintings, she is creative, intelligent, quite independent and has dreams and goals. She is a young adolescent woman and all that goes with that. She has a loving father. She is a leader, is caring, likes fun and has a wicked sense of humour. This is just a small part of Helen, the rest hidden by a sense of being swallowed up by what was happening in her life and by the effects of 'Depression'.
Helen was 14 years old. Helen had lived with her father since she was seven. This occurred after her parents separated, leaving her and her father living separately to her mother and two sisters. Helen would often overdose on Panadol to the point where she was damaging her Liver and it was believed that she would either do irreversible damage and/or take her life. Helen was at the time, (as she had done on a number of occasions) residing at the Womens & Children's Hospital. (WCH) She had had numerous admissions due to suicidal ideation and self harming behaviours. She had been diagnosed with 'Depression' and placed on medication. When Helen was not in Adelaide in the hospital, she lived with her father on Kangaroo Island, (K.I.). K.I. is approximately 112km from Adelaide and although we do not classify it as overseas! it is only accessible via ferry or plane and is clearly a rural/isolated area. It has a country hospital and Southern CAMHS visits on a monthly basis.
The referring issues were: suicidal ideation, running away behaviours, self harming, arguments at home, parenting, lack of communication, Helen's self abandonment, maintaining Helen at school, peer relationships, isolation and depression.
In a world where families can be fragmented and community is seen of lesser importance - isolation exists. Isolation can bring about it's own debilitating effects and is in itself problematic. For families living in isolated or rural areas where the problems can be exacerbated, service delivery often cannot meet their needs. How greater then are the impacts of this on a family or young person who struggles also with the effects of family breakdown, possible risk of homelessness, suicidal ideation and self-harming behaviours? How do we provide a service the family and young person will find helpful?
Helen and her dad John fitted the criteria but being a metropolitan service, how were
we to work with a family who lived on K.I. where we could actually provide a service that
would not only be helpful but where new possibilities could flourish?
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THE REFERRAL
The initial referral was made via the Hospital Links Program. The Hospital Links Program
is a joint initiative of Adolescent Services (Adelaide Central Mission) and the WCH. They
are based within the hospital and work with young people who have been admitted to a
hospital program and where issues exist for them around their living situation or the
possibility of their accommodation breaking down.
On referral the family (and may I say the system involved) had a problem saturated (see White & Epston, 1990) understanding of what was being presented. It was seen as too difficult and that there were little or no solutions or options. This, in itself, was harbouring and brought about it's own debilitating effects on the family and also the workers involved. For the workers, they felt unsure what would be of assistance to Helen and her family and felt stuck and fearful of the possible outcome. For John and Helen there was internalisation and vigilance.
John states, 'I had severe self doubt and a sense of inadequacy', 'I felt that I had no control, no matter what I said or did', 'It was overwhelming', 'I did not feel heard within the system', 'I felt that my daughter could be taken away'. Helen said, 'I was made to feel that it was hopeless', 'It was not worth it', 'I was told that dad was my problem', 'I was labelled as 'Depressed'.
The family and system were held within the patterns of depression and within ideas, understandings and beliefs about their lives, their strengths and abilities in not only unhelpful ways but in a way that was preventing them and the community from being able to support them in standing up to the effects and trickery of 'Depression'. It prevented Helen from re-connecting with the strengths that she had to stand up to depression and to a system that was becoming increasingly difficult to remove herself from due to such self doubt. It had her not trusting herself and others not trusting themselves to keep safe from the very real threat of death.
ISOLATION - Isolation-and with that the lack of services able to provide a support network-had the effect being felt threefold. What added information does 'Isolation' feed to those feeling it's effects?
Helen states, 'I felt trapped and the only solution seemed to kill myself', 'I felt scared and vulnerable because there was no support', 'Overdosing was a way to get off the Island', 'It made the depression even bigger and more confusing', 'I felt that no-one was helping me and that to be in Hospital was all I could have, there seemed no point'.
John said, 'I couldn't stay with her and the lack of communication assisted even more apartness', 'I felt like I didn't figure in it', 'I had no information on what was to happen or on depression', ''The lack of information or knowledge increased my anxiety even more', 'I felt exposed emotionally within the 'system' and hurt that we were not being treated as a family'.
These understandings contributed even more to depression and it's unhelpful cycles.
RISING TO THE PROBLEM & NOT LETTING 'DEPRESSION' BEAT US - THE MEETING - A discussion was held at YPS. This involved the key players only in regards to the referral and was not a case conference. It involved, the Manager of Adolescent Services, the Senior of Ruby's, the Senior of YPS, Hospital Links and myself as the possible counsellor. Due to the distress of the family it was important to gather together as much information before meeting with them to offer what we had and then consult with them about what they might find helpful.
This was the beginning of firstly, hearing the voice of the family and giving them back the power to have more of an influence on the decisions that were being made in their lives. Secondly, to challenging the more routine ways of practice and finding new ways of working, pushing our own levels of comfort, having to be even more flexible than we would normally be, gathering together the options available to the therapeutic and the practicalities of combining this and accommodation whilst working systemically.
- In what ways could we support this family to reach their goals?
- What could we do that would be different to what they had already had?
- How were we going to do this in the practical sense and stay connected with the services that were already involved - this is not the time to have a break down in communication or miss the things that were already working.
- What was the framework that we would provide that would incorporate helpful and
respectful therapy?
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COLLABORATION - THE BEGINNING
After meeting with the family who were very keen to work on the presenting issues and on
living together again without depression, the following things were put into action:
- The Hospital needed to continue the very important role of clinical case management and a protocol was developed to ensure that things ran smoothly.
- YPS would have the overall and therapeutic case management,
- A continued connection with Hospital Links who assisted in keeping the lines open between the Hospital, myself and Ruby's,
- Phone and e-mail contact with Helen's psychiatrist,
- A visit to the hospital ward rounds,
- Accommodation at Ruby's on a fortnightly basis. This was to be seen as respite in order to keep going home to the fore.
- Face to face therapy whilst in Adelaide,
- Hometime on the other fortnight with Tele-conferencing sessions. These were held between the Hospital and the CAMHS office on K.I and they were new and very exciting. We were greatly supported with this,
- Maintaining contact also on the hometimes via telephone interviews.
- Weekly meetings at Ruby's staff meetings, which also gave me an opportunity to meet with the Adolescent Services Enfield Campus (ASEC) worker to exchange information,
- Some time within the Hospital School during the times Helen was in Adelaide, and lastly,
- A visit to K.I. via car and Ferry, to touch base with Helen's school, it's principal, the school counsellor and the rest of Helen's family. When we work together, both services and families, the possibilities are endless and fruitful.
The return trip included Helen and her entire family on the Ferry. What a great opportunity this was to chat. I think Depression didn't like travelling!
There was a great need to treat with the highest regard the fact that Depression had already invited so many people into Helen and John's life and ensure that we were being systemic and not getting caught in systems abuse. A couple of very important things I kept in mind were, that I needed to make visible my intentions and work (maintain transparency) and maintain utmost confidentiality. (A sense of Isolation and Depression both feed off a lack of these in small communities and we did not want to contribute to this more). Only sharing information that the family were happy for me to share and gaining written consent for this to happen. Helen stated that, 'A breaking of confidentiality made it worse and trying to fit then into society and school was harder, as people were not told the truth and there were twisted rumours'. Being a rural community, everyone knew what was going on.
THE NAMING OF THE PROBLEM - 'DEPRESSION' - In my very first session and even on the ferry, I was able to start getting a new story, de-bunk the old, find exceptions to the old story, find an alternative one and separate the problem 'Depression' from the family - Externalizing. There were many exceptions and unique outcomes not the least of which was the decision they made as a family to challenge depression and venture into this program with a great energy to re-claim 'Life'.
For the concept of externalizing of problems in more detail, see White & Epston (1988/89/90)
In our culture there are many invitations for people who have experienced difficult circumstances to see themselves as the problem, as deficient in some way. This can result in people feeling helpless to take any action, or can restrict them to action that reinforces the problem. There are also many invitations to blame relationships for the negative effects of problems. Helen states, 'I was told that dad was my problem'. When this occurs, people often feel divided from each other at precisely the times that those relationships are most needed. The person is not the problem, the problem is the problem. Once a problem is seen as separate from the identity of a person or from the identity of a significant relationship, the person is in a position to take new action or to take new action together. It no longer speaks to them as their identity, the 'truth' about themselves. It begins to depower the effects of labelling/pathologising/diagnosing and reduces guilt and blame, yet leaves room for responsibility.
Depression is fed by routine and fear. It placed many invitations to us all to join in its fight to silence Helen. It can hold all of us in a pattern that promotes ignorance and where we hear the voice of depression over and above the voice of Helen or John.
Some of the say that Depression was having, included, 'It had me wanting to die, it kept secrets, others had more of a say in my life than I did, it stopped good relationships, it has people fearful, had others making my decisions, had me isolated, had me thinking that all sadness was depression, had me self harming, had me having no friends, had me thinking that I was a bad daughter, had me feeling guilty'. For John, 'It had me thinking that I was a bad father and that I had to monitor my daughter'.
Externalizing then became a focal point for both Helen and John re-claiming their lives back and having more of a voice and what they found to be most useful throughout therapy. Helen had stated, 'I don't want Depression to win and it be too late'. Helen was able to not be dictated to by the voice of Depression and have an understanding of her ability to be more responsible for her own life and life choices. For John, it allowed him once again to connect with his daughter and the possibility of re-claiming their lives back from this very negative and destructive force. He too stood up to it's invitations.
John said, 'Giving Depression it's own chair was not only educational but allowed me
the chance to get an understanding of what depression is and isn't. It separated
depression and allowed me to see that it was not an integral part of who Helen was as a
person' and Helen, that, 'It felt stupid at first but then it made sense'. 'You can look
at things from a different perspective'. 'I am a myriad of colours and other things, not
just depression'.
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ONGOING THERAPY - A NEW STORY EMERGES
This was a time where you could literally see depression going in and out of session but
where Helen was definitely dominant. In a fairly short space of time, 'Life' was to have a
say in many ways, such as, 'I was having fun in life, I was looking after myself, of
family, of being more loyal to myself and others, of friendships, of giving good advice on
LIVING, of making decisions for my own life, of re-connecting with the things that are
important to me, of having faith in myself, of getting on with my education, there is more
of my creative self, I'm not being policed by others and of being more in touch with my
spiritual self'.
For John, 'I was having faith in myself, I was more the parent I wanted to be and was able to set better boundaries and I was able to relinquish being a Manager of Helen's life and become a Consultant in her life. For further information and ideas on parents moving from Manager to Consultant, see, Riera (1995).
Unique Outcomes or Glimmers of Difference were being witnessed at Ruby's, on the Island and by other workers. Helen's and John's love and strengths stood stronger and greater than depression. Helen was emerging more and more. She was breaking the cycles of self harming and there were no hospital admissions. Helen said that, 'I was putting Depression on the back burner'- Helen's tricks (her ability to trick depression). Helen was noticing some differences between depression and sadness and was even able to laugh in the face of depression, finding humour within instances which normally would have had her caught up in depression having more of a say.
In an ongoing way, Helen and I would re-visit her goal sheet filled out at the beginning of the process. These were to: Starve Depression, Return home, Invite more fun into her life and to move house. John, in his continued efforts to support Helen and not Depression had them move physically from the airport which was isolated even from the main town of K.I. into Kingscote, supporting both of them to re-claim fun and connections with others in their lives and not just focus on school and work.
Helen was witnessing her own changes. During this time, a number of statements from Helen supported this. She said things like, 'I don't see the point in trying to kill myself any more-I want to stop the cycle'. 'I'm showing others the new me'. 'I don't want to go back to hospital any more'. She was surprised by this as the hospital had previously been used as a safe haven and humourous stories from Helen were emerging about depression. The externalization had been re-named by Helen, from 'Depression' to 'LIFE'. Helen also talked about being 'Happy' and 'I have low moods now'. 'I am ready to move on'. I even overheard her talking to her dad, starting the sentence off with, 'Now that I am getting better dad...'.
It was at this time that a colleague and I had started putting into practice the notion that young people consulting with other young people would be not only useful therapeutically but respectful to young peoples experience, expertise, and knowledges. It was a huge success and this is continuing to evolve. Helen was a consultant to another young woman who was having some similar struggles with suicidal thoughts and self harming. The young woman in question found it inspiring, we found it very exciting and for Helen, it was an opportunity to re-connect with the things that were most meaningful to her in her personal stand. The ongoing Tele-Conferencing broke the isolation when at home and promoted constant connections. Helen saying that, 'It was funny but it's good to be able to see the person and their expressions'. John thought that, 'It was really valuable'. 'It kept the problems exposed'. 'We could be open and honest'. 'Being face to face, gave it a flow'. 'It's a great achievement'.
Although we are not given to celebrating 'Rite-of-Passage' in our culture outside of christmas, birthdays, marriage and the like, we use it in our work as (this works particularly well in the context of Ruby's) a major factor in truely grounding change, making change newsworthy and giving credit to those that have worked so hard at standing up to the problems in their lives. This can be done at a major crossroads in the persons life eg; having a party to celebrate leaving Ruby's and returning home but also during the process with Therapeutic Letters as catch-ups on the persons progress to others, so they can act as an outsider witness to the changes. We celebrate not just with those directly involved but with the other significant people in their lives. This is done in a symbolic way with food, a fairy story and gift from the Ruby's staff, others sharing what they feel important and a symbolic gift and speech from me as the counsellor.
Sometimes the problem doesn't hear good news well and we need to be aware of the possible side effects of this. ie; the problem may fight back with what we call a 'HICCUP'. This is NOT the problem re-emerging but it giving another shot at having a voice, where it knows it has lost. On one occasion there was such a time where depression was whispering in Helen's ear and with the support of the hospital we were able to put that to rest. Instead of Helen going to hospital with the understanding that she was depressed and could not cope, with consultation and collaboration from the hospital and Hospital Links, Helen was packed for a holiday break! It was an opportunity to keep safe and break the cycle in a significant way. She packed a bag for HELEN and had a brief hospital admission. She symbolically packed: Her cat, her favourite dress, family, future, her dog, her friends, privacy, to name a few. (A re-framing to support 'LIFE'). Ruby's also sent along HOWARD the Frog! to keep her company and on the path to fun. For more information on Howard the Frog, see Sutherland & O'Laughlin (2000).
Helen returned energised to continue the work that she needed to do without another hospital admission.
The following is a copy of the speech that I read out to Helen at her celebration.
We have gathered here to celebrate a short but incredible journey, part of which is complete and a part which will continue. We are celebrating a 'Journey of Life' and in doing so, present you with your 'Life Box'. A place where you can keep your most treasured possessions. A way of keeping close the things you hold dear.
A way of keeping together the things that you have gathered on this journey and will continue to gather........the things that are........HELEN.
Helen is:
- More mature, independent and confident,
- A leader at school where others seek out her wisdom and advice and in the realm of the new frontiers with working with (and being successful with) Tele-conferencing,
- Closer to those that she loves and that love her,
- A talented artist,
- Building relationships based on equality,
- Taking care of herself,
- Following her dreams,
- In control of her life,
- Excited about the future,
- Loyal to herself,
- Strong, funny and able to be happy,
- A person whose braveness allowed others to explore different ways of going about things, of not having to be fearful and of not having to feel the heavy weight of Depression, and
- A person who took on the wisdom of a dear friend to celebrate Life.
These are just some of the things for your 'Life Box' and I am sure there will be many to come. There was a time not so long ago where we could have been tricked into believing that Depression ruled.
In September 1999 Depression was:
· Arguments · Negativity · Being unsafe · Running away
· Fear · Missing School · Time in Hospital · Bad relationships
· Anxiousness · Great Sadness
BUT........ Already by October/November it was apparent that Depression had under-estimated Helen's strengths and abilities and I quote: 'I'm going to make a stand'. 'It's working because of me'. 'I can look back now' and 'I can feel happy' (A word previously unmentionable). By December I asked you what advice you might pass on to other young people and you said: 'To love themselves' and to 'Not take everything to heart'.
I also asked you and your dad, What would be the one thing that you feel you will walk away with? Your dad said, 'My daughter, no matter where she is', and you Helen, 'LIFE'.
CONGRATULATIONS ANNA (March 2000)
THE LIFE BOX - Gifts are symbolic and meaningful to the work and the work that continues. They are not presents. This was literally a box. A box Helen could keep with her at all times. It holds the things that she feels are important to her. The things that relate to 'Life'. Keeping them in the box was to avoid them being lost but most importantly, that she could not get tricked by depression into believing that they were short lived or did not exist. It kept them safe. Things like: happy memories, her strengths, love and her beauty.
These questions were asked of both John and Helen:
- What did they find good or most helpful?
- What did they find most unhelpful?
John said, 'Someone to turn to within the system'. 'A Case Manager that stayed focused and particularly on FAMILY'. Helen, 'The Counselling. Externalizing. - My voice was louder and depression had less power'.
John said, 'Not gaining true consultation with the psychiatrist'. Helen, 'Being introduced to self harming as an option. I only had thoughts before and that the hospital system only look to fixing the medical'.
The following poem was sent by John to Helen. It holds great meaning in terms of his staying connected with her. 'It's my spiritual connection with my daughter'. 'An expression of love and of caring'. 'This was a point of survival for me-to find my sense of spirituality and to focus on LIFE'.
I SAID A PRAYER FOR YOU TODAY
I said a prayer for you today,
I prayed that He'd be near to you,
and know God must have heard.
At the start of each new day,
To grant you health and blessings fair,
I felt the answer in my heart,
And friends to share your way.
Although He spoke not a word.
I asked for happiness for you,
I didn't ask for wealth or fame,
In all things great and small.
(I knew you wouldn't mind)
I asked for priceless treasures rare,
But that you'd know His loving care,
Of a more lasting kind.
I prayed for most of all.
(Submitted by Dolly Palmer-a friend of John's and Helen's)
LIFE - Helen did return home for a lengthy time but now resides in Adelaide. She maintains a close connection and relationship with her dad. She is again persuing her education. Helen is now getting off her medication and although depression may attempt to have a say.......Helen is louder and happier. Helen is artistic and produces the most beautiful paintings, is creative, intelligent, likes fun and has dreams and goals - this is her beauty. 'I am a myriad of colours, not depression'.
CONCLUSIONS/RECOMMENDATIONS
What stands strong is that to work with families in isolated or rural areas CAN work
successfully and can work without having to be within the community. What the family found
helpful was working from a narrative approach, having their voice heard and being given
the power in their lives. Working collaboratively but with a case manager. Working with a
mixture of therapy and accommodation with flexibility to meet the individual needs. Having
set protocols that support them at times of hiccups.
What was less helpful and does not work is to see families as problem saturated, of services not meeting the needs of the uniqueness of families, that there are limited resources to meet the needs of families who live in isolation. That when things are not going well for families that they are blamed and the responsibility placed upon them instead of us questioning the way in which we work. When workers become neglectful, less mindful or complacent and protocols are not followed or seen as less important, this has the effect of damaging and undermining the work that the family and other services have already achieved. They no longer work toward the same goals and plans.
It is not only the role of workers and services but their responsibility to provide more for those in isolation and to respond to the needs of the community by venturing outside of their own comfort zone. Mostly we as service providers need to work with families from a base of integrity and only for what is good or helpful to the family or individual that seeks to consult with us.
John expressed his desire for a system that would incorporate a program specifically
for Depression. One with a safety net for those particularly in isolated areas, that looks
closely at isolation and it's effects and, that is a preventative program.
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[1.] White, M. & Epston. D. (1988/9) 'Re-Authoring of Lives & Relationships'. Interviews & Essays, Dulwich Centre Publications.
[2.] White, M. & Epston. D. (1990) Narrative Means to Therapeutic Ends, W.W. Norton & Co, New York.
[3.] Dulwich Centre Newsletter. (1996) No 3. 'Notes on Externalizing Problems'. ‘A spirit on it's own is easily broken’.
[4.] Riera, M. Ph.D. (1995) Uncommon Sense for Parents with Teenagers, Celestial Arts, California. Chap 1. Pages 1-8.
[5.] Sutherland, R. & O'Laughlin, E. (2000) 'Howard the Frog', Presented at Youth Services Models Conference, Adelaide.
ACKNOWLEDGEMENTS
[1.] John & Helen Van Der Giessen. "Congratulations and thank you, it was a privilege working with you"
[2.] Andrea & Cathi great editors and support. Thank you.
[3.] Robyn, John & Andrew for your encouragement, belief in me and support.
[4.] Daniel for your computer wizardry-thank you.
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