Relational by design

Mental health is relational: our systems need to see the whole picture

I am De Backman Hoyle, Director of Partnerships and Stakeholder Engagement at Mental Health Carers Australia, the national peak body representing the voices, experiences and systemic advocacy priorities of mental health families, carers and kin. 

When the same experience keeps appearing, it stops being simply an individual story. It can tell us something about the system. That is where lived experience becomes so important to systemic advocacy. Personal experience matters deeply, but collective experience can help us identify where policy, practice or system design needs to change. 

Looking beyond the individual

One of the patterns MHCA continues to see is that our mental health system is largely designed around an individual, while many people live their lives in relationships. Person-centred care is essential. But person-centred should not come to mean person-only. People live within families, friendships, households and communities. Those relationships may include family of origin, chosen family, partners, friends, kin or others.

A relational approach does not mean assuming family involvement is always appropriate. People must retain the right to decide who matters in their lives, who they want involved and who they do not.

What we are asking is that services become much better at understanding that relational world.

When someone experiences a mental health crisis in a shared household, for example, a service understandably focuses on the person requiring immediate care. But the impact does not necessarily stop when an ambulance leaves.

There may be children in the home. A partner. Parents. Siblings. Friends. Older relatives. They may be frightened, confused or unsure about what happens next.

First Nations approaches to social and emotional wellbeing have long offered a much broader understanding of health and wellbeing, including connection to family, kin, community, culture and place. Mainstream systems still have much to learn from relational and collective ways of understanding wellbeing.

Who are your people?

One practical change could begin with asking better questions. Rather than relying primarily on concepts such as “next of kin”, services could routinely ask:

• Who are the important people in your life?
• Who would you like involved?
• Who would you prefer not to involve?
• Who are you going home to?

The answers may be very different from what a traditional family is understood to be.

Family should not automatically mean biological relatives or family of origin. People should be able to define for themselves who their people are. Those relationships can also change over time.

That gives services a much richer understanding of someone’s circumstances while maintaining the person’s agency over who is involved.

Privacy should protect people, not prevent communication

Confidentiality and privacy are essential.

But we also need to become better at distinguishing between protecting someone’s confidential information and shutting families, carers and kin out of meaningful communication altogether. This becomes particularly important when someone is returning from an acute service into a shared home.

Families do not necessarily need access to every detail of a person’s clinical care. But they may need enough information to understand what to expect, what support is available, what responsibilities they are — and importantly are not — being asked to take on, and who to contact if circumstances change.

A clinical service has staff, systems, procedures and governance around it. A family home does not.

This is not about creating fear around mental illness or assuming risk. It is about recognising that discharge may involve other people whose lives and relationships are also affected by that transition. 

Protecting relationships

There is another consequence when services are not designed relationally. Families can gradually find themselves becoming “mini clinicians”. A partner becomes responsible for monitoring medication. A parent watches constantly for signs that something is changing. A sibling becomes the person coordinating appointments and services. Very quickly, an ordinary relationship can become organised around monitoring, treatment and responsibility.

I understand this personally as well as professionally.

I was married to a beautiful man, Andrew, for ten years before he died by suicide. We began our marriage as partners and equals. Towards the end of his life, however, I increasingly felt that I had become his nurse rather than simply his wife. That experience has stayed with me.

But what makes it relevant to my work now is that I hear variations of that experience from families across Australia.

• Parents who feel they must become case managers.
• Partners who feel responsible for monitoring another person’s wellbeing.
• Family members who fear that if something goes wrong, they will somehow be held responsible for not preventing it.

Relational by design

For Mental Health Carers Australia, this is ultimately a system reform issue.

Families, carers and kin make an extraordinary contribution to Australia’s mental health system. But they should not become an unpaid substitute for a properly resourced workforce. Nor should they only become visible to services when somebody needs them to perform a caring task. Families, carers and kin are people in their own right, with their own relationships, health, work, needs and lives.

This is why MHCA is advocating for mental health systems that are relational by design.

The opportunity is not to move away from person-centred care.

It is to make it bigger.

To recognise that people do not live as isolated individuals and to design a mental health system that reflects the way human beings actually live: in relationship with one another.