"My mummy didn't wake up this morning," is what Christine Mulligan remembers telling a teacher as she and her classmates lined up to go into assembly at her national school.
She was seven or eight at the time and it’s her earliest memory of a suicide attempt by her mother, who suffered from depression. Christine had woken up to her dad “shouting and screaming” when he found his wife had taken an overdose.
Her mother was hospitalised for a time and then returned home, but nobody ever spoke to Christine or her three siblings about what had happened, or her ongoing mental health problems.
“I don’t know what sort of depression she had,” says Christine. “She might have had low mood after the first child and then it got worse.”
Having had a difficult upbringing in St Teresa’s Gardens flats complex in Dublin and leaving school at age 11, Christine’s mother was almost inevitably going to find parenthood a huge struggle. Her husband, who she met while working in a dog food factory, had a succession of low-paid jobs to try to support the family, but was a remote figure to his children.
“She did her best,” Christine stresses, but having three children under the age of four – Christine had an older sister and younger twin brother and sister – was a huge pressure, which was compounded by poverty and periods of homelessness in 1970s Dublin.
Christine remembers a lot of moving about, including two stays in the high-rise Ballymun flats – once as squatters and another time they were housed there – before settling into a Corporation house in Kilbarrack. But it wasn’t until she was a teenager that she realised how different her upbringing was to most people’s.
“You just live what you know,” she says. “I also think each child in the family copes with it in their own particular way. My way of coping with it was to be the good kid, to try and do well in school, to try to keep the peace.”
Mummy's not feeling well, Daddy's not feeling well, so be good
Despite the turbulence, Christine says of her mother: “I liked her, I admired her. You learn to adapt. When she wasn’t in a good mood or wasn’t feeling well, you’re conscious of that. I was changing my behaviour to deal with it. The way I describe it – through years of therapy – is that you learn to take the temperature of the person and act accordingly. Mummy’s not feeling well, Daddy’s not feeling well, so be good.”
Others might have got into trouble, played the clown or simply got lost. Her mother was in the habit of self-medicating with alcohol, but “she got sober when I was about 12”, says Christine. “She tried to get help for the family then.”
By the time Christine was 22, in 1992, she was working as an assistant manager with Paddy Power Bookmakers and in a relationship that was to lead on to marriage.
“I thought I was doing reasonably well,” she recalls.
But the suicide of her brother John (20) that year shattered the illusion for her and her sisters that they had left their troubled past behind them. He too had seemed as if he was moving on to a brighter future – he had a job, a girlfriend and a good circle of friends.
“But he had never learned to talk about anything; he was just trying to cope,” says Christine.
His death “triggered the realisation that we had a lot of challenges, that you either deal with them or they will affect your whole life. No one wants to realise they had a difficult childhood. You’re functioning, you’re getting up in the morning, but it is like the ‘black dog’ hanging over you.”
She recognises the “contagion effect” of such a close experience of suicide. It’s a way out that “becomes part of your repertoire, an acceptable option”.
Soon afterwards, Christine went into therapy for the first time. She knows now that her early years have affected all her relationships and how she relates to people.
As a child she had to become so skilled at reading other people’s feelings, that was all she focused on. “I didn’t know how I felt. I was so tuned in to the person who was unwell and the need for them to be okay.”
Christine was married at 24, but separated by 30. “I had no idea how to be a wife,” she says simply.
A longed-for return to education was what transformed her life – even though it meant selling her home to fund it. She was accepted as a mature student at Maynooth University to study psychology and graduated with first-class honours last year, coming second in the class.
Now she is doing a PhD at the university's Centre for Mental Health and Community Research as part of a team of psychologists being funded by the HSE to help develop services aimed at supporting the whole family when a parent has mental health issues. It has been estimated that up to one in five children and young people live in such families.
In the first stage of the PRIMERA research programme, headed by the centre's founder, Prof Sinead McGilloway, they looked for an evidence-based family support intervention that could be offered where a parent of children aged five to 18 years has mental health difficulties. The programme they have chosen for piloting and evaluation is Family Talk, developed by Dr William Beardslee, a Harvard professor of child psychiatry.
Already being used on a very small scale in Drogheda, it’s a six- to eight-week course that includes sessions for parents, children and the whole family together. It can be conducted in the home or at a clinic.
Among its aims is to help children better understand their parent’s problem so they don’t blame themselves for what’s going on and also build their resilience to developing their own mental health difficulties.
Well-intentioned parents frequently avoid discussing their mental problems with children but this silence can compound the confusion, according to research co-ordinator Dr Maireád Furlong, as the youngsters struggle to make sense of what’s going on.
Mental health professionals need only to do a 10-hour online training programme before they are ready to deliver Family Talk. Some 13 mental health sites – run by the HSE, Tusla and St John of God – are participating in the research.
It is an intervention that targets all mental health conditions, although parents with active psychosis or for whom substance abuse is the primary issue are excluded, as are families where there is clear evidence of parental conflict, such as separation. Families need to be functioning and able to engage with the course, says Christine.
They have customised Family Talk to an Irish context, adding a part that involves the family devising a care plan in the event of a crisis.
“So, there is a procedure in place if mum or dad has a crisis attack or needs to be hospitalised,” says McGilloway.
In liaising with mental health services and sites across the country, it is clear that on the ground health professionals recognise the need for a family support programme but there is no systematic intervention, she explains.
“The HSE is trying to come up with standardised practice. But it won’t be a magic pill,” she cautions.
Working on this project, Christine reflects on what might have worked for her and her family.
“I ask myself two questions – what would work and where do you start? I would start further back than my mother – my grandmother. And if she was here, she would probably want me to start further back.”
As for what action was needed: “Our family had so much going on, we needed additional resources, additional support, which hopefully is more available these days and will more likely to be available with something like Family Talk.”
Today, at age 48, Christine can say: “It’s a very good time of my life – even though I sold my house.” But she has no regrets about that because the third-level education it funded has been life-changing.
She thinks she will probably always be predisposed to depression but knows what she needs to do to look after her mental health – eat well, exercise and spend time with her very supportive friends. She also pays tribute to Maynooth University’s support for mature students like her and to McGilloway’s inspiring mentoring.
A bad childhood doesn't stop and then you get on with life
However, “a bad childhood doesn’t stop and then you get on with life,” she adds. “A friend of mine said ‘it’s like walking up a hill in high heels backwards’. It’s like you are always pushing against the grain.”
It’s why, for Christine, the motivation for researching what could help contain the generational ripples of mental illness is not just professional, it’s personal too.
Is a mental health patient a parent and, if so, what can be done for the children?
It's a basic question that healthcare services need to be asking and answering says a leading expert on family mental health, Dr Adrian Falkov.
Common sense would make you wonder why services wouldn’t see the relevance and importance of somebody being a parent, he remarks, and, when that parent is affected by illness, why that wouldn’t be even more important.
In Norway, it has been mandatory since 2010 that whenever a parent presents with a mental illness or addiction that the services check on the wellbeing of their family. Here, a mental health patient will not necessarily even be asked if they are a parent.
In preliminary work for a study on effective ways to support families of parents with a mental health difficulty, the team from Maynooth University’s Centre for Mental Health and Community Research asked various mental health services around the country how many parents they were seeing.
“They couldn’t tell us. It wasn’t recorded,” explains the head of the centre, Prof McGilloway. People attending services are treated as individual patients.
“If you do ask about family you could open a whole can of worms, such as child protection, that the professional can’t deal with and doesn’t feel competent to deal with. So, there is a reason this doesn’t happen,” she comments.
There is also the fear, as PhD researcher Christine Mulligan points out, that a parent who is questioned too closely about children at home may draw back from treatment for fear the children might be taken into care. Yet, if they knew that a family welfare approach was standard practice, they wouldn’t feel targeted.
“People are more than just individuals; they come in a family and exist in a family and, therefore, their mental ill health happens in a family context,” she comments.
A child and adolescent psychiatrist working in Sydney, Falkov tells Health + Family during a recent visit to Ireland that, globally, there is growing awareness of the need for a family focus. There is less polarisation now between the, historically, very separate adult and child services, "but there's still a long way to go".
He was here to lead a masterclass for more than 80 mental health professionals organised at Maynooth University earlier this month, as part of the research team’s brief to promote a “think family” approach. He sees worldwide how organisational and system barriers, as well as stigma, hamper the ability of healthcare staff to be family focused.
Falkov devised the "Family Model" training tool to help professionals have a better understanding of cross-generational adversity and apply it to their work.
He says it’s “exciting” that Ireland’s HSE is taking a systematic approach to this issue and striving to gather good evidence through the Maynooth team’s three-and-a-half-year PRIMERA research programme.
“Regardless of what the results show, the mere fact that there has been funding to get this off the ground will have helped raise awareness very significantly and that is always important.”
In places where he has worked it has typically taken about five years of awareness-raising before things begin to change.
“The potential of what is happening in the Republic is a much quicker move from awareness into action.”
Falkov has been visiting Northern Ireland over the last eight years to help develop a “think family” approach across child and mental health services there. The impetus for changes in the way the North’s services were operating came in the wake of the tragic case of Madeleine O’Neill, who smothered her nine-year-old daughter Lauren before taking her own life at their home in Carryduff, Co Down, in July 2005.
Her estranged husband told the inquest into their deaths that he had never been told his wife, who was being treated for depression, had said to doctors that she might harm their daughter. In 2010, he received damages from the Belfast and Western Health Trusts who apologised for “inexcusable failures” around O’Neill’s treatment and said they accepted the death of Lauren should never have occurred.
Falkov says he is often asked what is the thing that will make the difference in getting a family-based system embedded in services.
“There is no one thing,” he explains. Policy on its own is not enough. “Training frontline staff alone is not enough, there needs to be leadership – at central, regional and local level.”
Finding resources is always going to be tricky, he acknowledges, but “investing in targeting relationships is good value”. This approach recognises that not only does the adult or child affected by mental difficulties need immediate assistance but they are in turn connected to a child or parent. Supporting the parent helps the child which helps the parent; or helping the child helps the parent to help the child.
“The potential yield in targeting relationships,” he adds, “is doubling up, it’s not just the individual.”