Recovery in a Family Context: Experiences of Mothers With Serious Mental Illnesses

Introduction

Personal recovery is a unique journeying for those experiencing a mental illness, however mutual underlying characteristics and processes are at present becoming better understood (one). Distinct from clinical recovery, which emphasizes a remission of psychiatric symptoms, personal recovery is grounded in the subjectivity of people who accept live experience of mental illness (2). Personal recovery is concerned with holistic life functioning and social participation and agency, regardless of the presence of ongoing symptoms (iii). Recovery experiences are unique and private, and also differ for men and women due to the influence of gender (four).

Identity, and particularly the development of a positive sense of self that is less affliction dominated and more force based, is one of the key processes of the Chinkle personal recovery framework developed by Leamy et al. (1). Resulting from a systematic review of personal recovery literature, the CHIME framework highlights Connectedness, Hope, Identity, Meaning and Empowerment equally core categories that transform in a recovery journey. The significance of redefining and reclaiming a valued identity may comprise "determining the management of one'due south life, grieving for lost opportunities, and yearning for belonging and acceptance" (5).

The ways in which mothers with mental illness depict their identity and the influences upon information technology inside the procedure of personal recovery, has remained peripheral within recovery discourse. The aim of this report is to explore the ways in which mothers with mental illness describe their identity, and the factors that support or hinder development of a positive identity. Critical inquiry aims to reveal and question social inequalities that are embedded inside stereotypes (half-dozen). This current written report adopts a gendered lens to examine the identity experiences of mothers with mental illness, and to investigate multiple identity possibilities including and beyond motherhood.

Identity Theory

Identity is broadly defined as one'southward cocky concept and is synthetic through self-awareness of what and who one is "like" and "not like" (7). Identity is synthetic within one's social and cultural context (8) and is therefore related to the construct of connectedness. Identity is a highly contested concept within feminist theory. An overarching theme is that gender based identity is predominantly oppressive. Butler (9) has problematized the concept of gender identity every bit the reproduction of the subordination of women, and explored the means in which it is reproduced through linguistics. She also questions whether identity is a stable and continuous entity, and if it is static, the social regulatory structures that produce this upshot:

'To what extent is 'identity' a normative ideal rather than a descriptive feature of experience? And how do the regulatory practices that govern gender also govern culturally intelligible notions of identity? In other words, the 'coherence' and 'continuity' of 'the person' are not logical or analytic features of personhood, merely rather socially instituted and maintained norms of intelligibility' (p.23).

Côté, defines identity equally multifaceted and states that "manifestations of identity be at 3 levels of analysis; the subjectivity of the individual, behavior patterns specific to the person and the private's membership in societal groups" [(ten), p. viii]. Within psychology, these differentiations have more than broadly been separated into two categories: personal and social identity.

Personal identity relates to the internal characteristics including attributes and values that ane recognizes as inherent to one's self concept. Social identity meanwhile, reflects how individuals view themselves as affiliating with and belonging to detail societal groups. Vocational, family, community, political, or gender-based categorizations are realms in which social identity may exist.

A key debate in identity theory is whether the self is essentially a stable and indelible entity, or whether information technology is constantly changing and evolving (7). According to self-schema theory, the core identity constructs of an individual are thought to remain stable over time, although at that place may be some change in the more peripheral aspects of one'due south identity (11). Rosenfield (12) used schemas relating to self-salience, to explicate disparities in mental health outcomes beyond gender, race and class, where a social determinants framework was ineffective in accounting for results that were inconsistent with structural inequality. Self-salience is associated with the relative importance individuals place on self, vs. the collective (13, 14). Rosenfield (12) cites the gendered socialization processes that contribute to the social structure of femininity and masculinity, and recognizes how these differ in relation to race and civilization (15). Historical and enduring social conditioning underlies the gendered internal self-salience tendencies that predispose white women to experiencing more internalizing problems (e.yard., low) and white men to have a greater prevalence of externalizing bug (e.thou., aggression) (12).

In contrast, self-categorization theory is based on the assumption that individuals' identity tin can and does change and evolve in response to the social and environmental context in which people alive, and in response to external and internal processes associated with major life events. Ontorato and Turner (7) compared the ii theories and constitute evidence to support self-categorization theory, with 2 studies demonstrating "the dynamic nature of cocky" (p. 276) that is context dependent. Cocky-categorization is a useful theory to inform exploration of the influences on identity development occurring through recovery from mental illness. Underlying assumptions imply that recovery emerges through social and psychological processes of personal change and development (1). The depth and latitude of self-reflection and change embedded in many of the subjective narratives of those with lived experience in mental illness and recovery, advise that recovery entails a transformation at a deep psychological level, not merely some pruning or enhancement on the margins. Thus, cocky-categorization theory relates to this report.

Although gender identity tin can exist a source of solidarity amid women, information technology is more often problematized inside feminist fence every bit a site for the reproduction of existing power differentials and maintenance of patriarchy. Inside feminist theory:

"…the reproduction of normative identities cannot be understood simply every bit a question of positioning within language just equally a lived social relation that necessarily involves the negotiation of conflict and tension" [(16), p. 185].

For women who are mothers with mental affliction, those conflicts and tensions may exist the precipitant besides every bit the result of the psychiatric diagnosis and subsequent handling and recovery. Ane method of developing deeper agreement of lived social relations is through amplification of the voices of those women who are marginalized in ascendant discourse. This report aims to contribute to that endeavor.

Mental Illness and Identity

Mental illness has been characterized every bit a loss of self (5), equally psychiatric symptoms may muffle or distort an individual'southward skills, knowledge, values and attributes. Social identity can also be disrupted as the illness ofttimes manifests in ways that prevent people from continuing in social roles that they had previously occupied and enjoyed (17). Individuals have spoken of enduring defoliation, grief and regret as they seek to reconstruct a sense of self and reconcile the differences in their identities before, during and after the mental disease experience (eighteen).

Researchers have explored the relationship between psychiatric symptoms and disruptions or incongruence in self-concept (19, 20) including models of conceptualizing and mitigating the impact of complex trauma on ones' identity and healing (21). Wisdom et al. (v) found loss of cocky to be the most prominent focus of narratives, with the affliction "often described as taking away…their previously held identity" (p. 491).

Feminist writers accept observed that historically, society's response to mental illness in women has resulted in sanctions for deviance and non-conformity to the prevailing cultural expectations [e.one thousand., (23)]. A focus on social "integration" and adaptation of the private, rather than advocacy for social change to create more equal and accessible social environments that foster diversity and inclusion, are axiomatic in critiques of the recovery paradigm (iv, 22).

Mothering With a Mental Illness

Mothering with mental illness is increasingly mutual (24, 25). Studies conducted with mothers with mental illness take emphasized the importance of a mothering identity to women in providing meaning and purpose (26), love and connection (26), and fulfillment (27).

Researchers have highlighted that parenting stress tin compromise mental health (28–30), and discovered that mothering confidence and competence tin can be undermined past the scrutiny and prejudice imposed by over-zealous service providers (26, 31) and family members (32), who are often operating within a risk disfavor framework.

Shor and Moreh-Kremer (33) emphasized the strengths for women with mental illness in being able to claim a normative maternal identity, thereby reducing their vulnerability to stigma and alienation. Within that written report mothering identity was compared to mental illness identity, without consideration of other potential sources of identity in women's lives. While there may be individual benefits to conforming to gendered norms, if this is through developing a public persona that is incongruent with 1's internal value system, and acceptance of oppressed social status, there volition also exist psychological costs (23).

Aim

The aim of this study was to explore how a accomplice of Australian women who were mothers with mental illness described their identity, and how this related to personal recovery from mental illness. The research furthermore aimed to explore the factors and processes that mothers with mental disease describe as influencing their identity.

Method

Constructivist grounded theory (CGT) methods were employed to gather and analyse rich descriptive qualitative data (34). Grounded in feminist understandings of gender inequality that tin can issue in and exacerbate the effects of mental disease, the research aimed to amplify the voices of women from a marginalized population grouping (35). Congruent with feminist approaches to research, CGT challenges the objectivity claims of positivist methods, instead advocating for transparency in acquittance of the values, perspectives, experiences and biases of the researcher which all influence the research decisions, processes, and outcomes (34). CGT emerged in the 1990'southward [e.g., (36, 37)] in response to the epistemological assumption that if "social reality is multiple, processual, and constructed, and so we must have the researcher's position, privilege, perspective and interactions into account as an inherent function of the enquiry reality" [(34), p. thirteen]. While traditional grounded theory methods emphasize that researchers go far at their ain data fresh, without prejudice or influence from previous studies (38) this sequencing is non required for undertaking constructivist grounded theory every bit the background inquiry and theoretical context investigated, contributes to the unique subjectivity of the researcher. Equally all experiences in the social world influence the perspectives, language, assumptions and biases a researcher brings to each project (34), it would be exceedingly ineffectual to refrain from reviewing literature as just one of space potential influences. Hence in this study, literature on identity and gender were explored prior to the information drove with participants, with a more focused search ensuing after the categories were formulated.

Procedures

Post-obit ideals approving from two wellness service and one academy Human Research and Ethics Committees, mental health clinicians from a regional clinical mental wellness service supported recruitment processes by promoting the study amidst eligible women on their caseloads. Steps were taken to ensure no harm or distress was caused, and that women felt comfortable to end or pause the interview at any time. All interviews were conducted past a researcher who was also an experienced social worker employed as a senior mental wellness clinician and informed consent was obtained in writing. Local services guides were developed and distributed to participants in the effect that the interviews triggered psychological response requiring follow up.

Ix women were recruited via clinical mental health services, and the remaining 8 from the general community via social and print media (promoted on Twitter and in local newspaper manufactures). Interviews were conducted past 1 researcher (RH), and consistent with CTG procedures, iv of these 17 women were interviewed on more than than one occasion as function of theoretical sampling. These participants were invited to participate in a 2nd interview due to specific characteristics they possessed, that meant they were able to provide data that could increase agreement of phenomena relating to emerging codes. A total of 21 interviews were conducted, the mean duration being 42 min. The participants were at different stages of recovery. None of the women were in an astute crisis or experiencing agile symptoms at the time of the data drove, although ane woman had been hospitalized within the final calendar month, and half-dozen were engaged with a clinical mental health service at the time of the interview. Three women were supported by a community mental wellness service and the remaining eight reported not receiving whatsoever specific mental health service at that time.

Interviews were conducted in person within a confidential space at various community health venues that were attainable to participants. Interviews were audio recorded and transcribed verbatim. The interview schedule was open up ended and flexible, containing questions pertaining to women's experiences of personal and social identity. The interview schedule is bachelor every bit a Supplementary Fabric. To fix the context, women were asked almost their mental illness and recovery journeys. Women were then asked broad questions regarding how they describe themselves, their social roles, personal characteristics, if and how the way they see themselves has inverse over time, nigh their mothering and parenting, how they envisage others see them, and what or who influences how they view themselves in various settings (e.g., work, mothering/family, community). The full recruitment and interview time frame was from July 2015 to February 2016.

Information Analysis

Data analysis occurred meantime with data collection, coding and reflection starting time immediately later on transcription of the starting time interview and continuing later on each interview. Analysis consisted of initial coding following close reading of all data on multiple occasions. Memo writing, purposive sampling, focused coding, mind-mapping were later undertaken to enable development of categories (34), hence the categories emerged straight from the data. Regular dynamic discussion amongst the three member inquiry team stimulated analysis and questions relating to the emerging categories. This led to second interviews with some participants to provide additional details to define the properties of emerging categories, as consistent with purposive sampling.

Participants

Participant characteristics are summarized in Table ane. A full of 21 interviews were conducted with 17 women who were all mothers with a psychiatric diagnosis. The women were a heterogeneous group and varied in relation to their living arrangements, socio-economical status and cultural groundwork. Ages ranged from 23 to 53 yr, with an average age of 36.29.

Tabular array 1. Participant characteristics.

Results

The study resulted in identification of six categories surrounding the concept of identity. The categories name psychological or social processes that were predominant within the data collectively. "Defining self" explores how women describe their self-concept and highlights the of import elements of personal and social identity. Equally mothering was a cadre component of participants' identity, the categories "becoming a Mother" and "being a 'good Mum'" illuminate the human relationship between women'due south mothering role, their mental disease and their recovery journeying. The human relationship between an illness identity and a mothering identity is explored in these sections. The category "feeling different" focuses on the women's experience of defective a social identity and the implications of this on their personal identity. The terminal two categories reflect women's recovery progress, and highlight the importance of developing a positive identity, for attaining other personal recovery outcomes such every bit empowerment and significant in life.

Defining Self

In describing their sense of self, all of the participants sought to contextualize their current temporal personal identity within their life histories, and inter-relational experiences, first in babyhood. Ten women shared accounts of trauma from interpersonal violence occurring inside childhood and/or adult relationships, and it is non known whether the remaining women may have also experienced violence but not disclosed. Through articulating key determinative events, the women sought to construct identity narratives that provided meaning to explicate their current circumstances, including their mental illness diagnosis.

Personal and social identities were described by participants as changing and evolving, while too containing stable components that persisted over time every bit illustrated by the assertion "I've always been this mode" (P7). Participants described their identity in relation to their personal attributes, social roles and key relationships. Not all women were able to eloquently describe themselves, however there were exceptions:

"(I'm) a woman, a female parent you know, I'thou a feminist, I'm an atheist, I'chiliad left fly, very left fly in a lot of ways. I'm very politically minded, I'g very also socially conscious I guess. I do a lot of social activism. I'm bisexual so I've done a lot of candidature for marriage equality and stuff similar that. I'grand very creative… I exercise a lot of crafty stuff. I dearest having kids considering it gives you an excuse to colour in… I exercise a lot of puzzles, I watch probably way too much television and movies, I'thousand a huge film buff. I dearest politics besides" (P11).

Moral characteristics such as honesty, independence, generosity and inventiveness were viewed positively in the ways in which women viewed themselves, and they validated this through reflecting on how others might see them "I retrieve people would describe me as dainty and caring" (P13). Recognition of their own resilience was also axiomatic (due north = nine) in comments such as "…sometimes I look back on what I've coped with and I think, wow" (P5).

For other women, there was recognition that attributes that had been characterized as strengths prior to the mental disease feel could also become barriers to the help seeking that may be required to address mental health challenges:

"I would describe myself as very independent. Probably too independent… I like individual sports similar running and tennis. I've never really played team sports. I like to reach, like at work I became fairly obsessed with achieving at piece of work. Just that was another thing after having the baby. It was very dissimilar…" (P2).

The social roles that the women identified embodying were relational, vocational, and community orientated. They included mother, sister, daughter, partner, friend, worker, health professional, educatee, mental illness advocate or educator, committee member and volunteer. Relationships with others in these spheres contributed to how they viewed themselves, and their personal identity could exist especially susceptible to messages they received from significant others regarding their performance within those roles.

Four women referred to their religious affiliation equally being of import in defining their moral and upstanding framework. Although three women spoke of attention church related activities, they did not view themselves as sharing many characteristics with other members of their church building except for their religious beliefs, therefore this was salient for personal rather than social identity.

Cultural identity was discussed by five women, two of whom were of Aboriginal descent (P7 and P8). Cultural disconnection was apparent with one of the women who indicated she knew niggling of her heritage as her Aboriginal father had died when she was young. Another Ancient woman had experienced significant trauma during babyhood and in adult life and had lacked opportunities to develop cultural cognition or connection, stating "I want to know my culture, just I don't desire to do my culture" (P8).

Participants articulating devalued personal identities were more likely to be in roles or relationships where they derived niggling pleasure or fulfillment:

"I have issues with my work and considering my boss is bully… when they cut my hours I took it really personally and I couldn't go to work the side by side 24-hour interval–I just cried" (P16).

Some women had difficulty describing themselves, identifying their strengths and imagining themselves in the future: "at the moment I can't see past tomorrow… I'd really like to enjoy things in my life a little bit more" (P15).

Identity across different domains could manifest in either positive, socially valued ways, or as negative and socially devalued. For example, a mothering identity could be positive if 1 perceived oneself to be a "good" female parent, and felt a sense of belonging to a mothers' group. Alternatively, a mothering identity could be experienced as negative if one considered herself to be scarce and incompetent, thereby judging herself as a "bad" mother. Similarly, if a woman held a position of esteem within the community as a commission member in a sporting gild, this would foster positive personal and social identity beyond other domains, whereas a lack of community recognition or a sense of social distance could contribute to a devalued identity reinforcing isolation and social exclusion.

Becoming a Mother

"When I gave nascency, I felt connected to something bigger and stronger than myself. I'one thousand not religious, but I'grand spiritual. So I felt connected to the bigger scheme of things like connected to other women and the feminine force of the universe" (P11).

Becoming a female parent was a particularly significant component of women's self-concept. It could transform a woman's personal and social identity, fostering a deep sense of connection and meaning. Nonetheless, information technology could also negatively bear on a woman's view of herself if she struggled to experience competent in the role. Variety was credible in the responses the women had to embodying a mothering role and identity. For some it was an identity they immediately embraced and had always expected. The majority of participants (due north = 12) had always had aspirations of parenting, and one woman with her partner had been planning the pregnancy for some fourth dimension, including changing psychiatric medication and exploring fertility options. Having a baby brought a sense of empowerment and fulfillment for 8 of the participants. For one woman information technology was an opportunity to practise her ain autonomy and make choices that would not necessarily exist endorsed by her ain female parent;

"I breastfed until 21 months and I loved it. And my mum said 'don't y'all think it's fourth dimension you gave it upward?' at half dozen months. And I'yard similar, hey, I felt something was right" (P5).

Nonetheless, the experience did not always live upward to expectations, especially in the early days and weeks.

"I hid it from the maternal and kid health nurse that I wasn't coping and and so on the Friday I'd had enough and then I rang (family services worker) and said 'I demand your assist"' (P10).

For four women, all of whom had relished the idea of motherhood since babyhood, childbirth was accompanied by debilitating postpartum low when they had idea they were emotionally prepared. This left them with guilt and regret for the aspects of early on parenting that they missed.

Experiencing breastfeeding difficulties was a source of pregnant stress and eroded self-confidence for four women. One adult female delayed disclosing her decision to bottle feed to her new parent's group, fearing social rejection:

"Information technology took me probably two weeks to tell them that I wasn't breastfeeding, because I was just so anxious about it because everyone else was breastfeeding and I was similar, oh they're going to want to kicking me out of the group, yep they won't want to talk to me ever again. Merely in one case I told them they were really supportive" (P17).

Having responsibility for a child prompted two women to re-assess their social beliefs and temper their anger. They explained how accepting the responsibility associated with caring for an infant had led them to terminate drug use, necessitating the severing of social relationships that would undermine this new salubrious lifestyle selection. This assisted in them feeling greater competence in managing emotions, which led to a more positive identity.

Becoming a mother could have positive or negative implications for the women's personal identity. This was partially influenced by the availability of supportive relationships and assist to adjust to the early parenting stage. How women perceived themselves to be performing in the mothering function profoundly shaped their identity, equally did the quality of their relationships with family members and health professionals and the means in which their inherent value was reflected through interactions within these relationships.

Another factor was whether the women's mental illnesses emerged before or after they became a mother. While 6 women had been given a psychiatric diagnosis prior to becoming a mother, an boosted 7 participants expressed the conventionalities that the mental health issues that eventually led to the subsequent diagnosis (after motherhood) had existed for many years, in some cases from childhood or adolescence. In these situations women described the mental illness label every bit providing an caption for psychological, cognitive and behavioral events, along with the opportunity for enhanced social identity through developing peer relationships.

Beingness a "Good Mum"

A "Expert Mum" was defined as accepting responsibility for one'due south children, prioritizing her children's needs over her own, existence present and responsive and "making it fun" (P7); using humor and actively engaging in play. Attention to children'southward emotional needs and being available was a role of this: "I want to be the person that my kids volition come and talk to me when something's going on, you lot know. Instead of hiding that away" (P7). All of the women interviewed expressed a desire to be identified by others as a "good mother." Furthermore, they wanted to embrace this label for themselves, although for three participants reconciling their thoughts and emotions regarding the mothering role with an ideal self-as-mother, was problematic. One woman rationalized that she wasn't a good mother considering

"…most of the fourth dimension I experience like I'm just getting through… it's the extras that play with the listen and question how well you lot are doing. Am I stimulating them plenty? Am I doing the right things for learning at this age?" (P2).

Characteristics of being a "good" mother ranged from coming together children'due south basic needs for nutrition, sleep and intellectual stimulation to being physically and emotionally available to children; "a good female parent is showing love to their child, their little one, talking to them, validating their feelings… understanding his indicate of view" (P5). It involved persisting through hard days. Persisting entailed getting up in the mornings despite burnout or symptoms of low, putting "a grinning on a lot in front end of them and for them" (P7) and for two mothers, remaining in undesirable employment to provide financial stability. In speaking about striving to exist a expert mother, two participants referred overtly to the sexism embedded in their own interpersonal relationships that saw them taking master responsibility for child rearing while their husbands enjoyed more leisure time.

Viii women expressed sadness and regret regarding their ain upbringing. Attributing their subsequent mental illness to the cumulative touch on of trauma, abuse, fail and disadvantage, participants felt that if they had been raised in a family with a responsive developed figure circumspect to their needs, their lives may have taken a different path. This fuelled a desire to exist present and considerate and sensitive to their children's traits, strengths and needs, even within challenging socio-economical circumstances.

"Making sure I do a good job and (my child) gets a good education and simply the fiddling things, speaking to him nicely. I've never always yelled at him, I don't believe in that and I don't like people who smack their children" (P6).

Despite all-time intentions, there were times when women's stress levels were loftier and their mental health was compromised. They became enlightened of how difficult this high expectation of parenting was in such times. For five women, serious concrete wellness atmospheric condition such as pneumonia besides took a toll. At this time children.

"…learnt to go very independent and it was hard to parent them at that fourth dimension. I didn't have the free energy to field of study them and I noticed a lot of things went out the window—just their manners and the manner they behaved and stuff—like I just couldn't be a good parent" (P16).

Breaking the pattern of cycles of intergenerational poverty, trauma and substance use were important to women in demonstrating their parenting attributes. They hoped for easier life circumstances for their children and hoped to guide them toward healthy choices:

"It'southward being able to see beyond their hurting and just walk with them and be their friend and guide them and show them this is what Mum and Dad take been through and this is why we don't desire y'all to go down this path" (P1).

Viewing oneself as a good female parent therefore had a positive impact on personal identity, while feeling incompetent or guilty had the opposite outcome. Women used dissimilar measures to assess their parenting capabilities however an increased chapters for cocky-reflection and self-compassion was associated with greater progress toward recovery.

Feeling "Unlike"

A sense of disconnection and alienation from peers and family members pervaded development of a valued and intact self-concept for a number of women and they related experiences stemming from childhood to illustrate this. For some this was characterized by additional sensitivity, "I was a very clingy needy child" (P16) or having different needs and abilities to siblings "when we were younger I would make clean (my sister's) room or practise stuff for her simply so I could spend time with her. Because nosotros're very different" (P10). These examples suggest an unmet need for nurturing and connection in childhood. Resulting from this was a fragmented sense of cocky that was dominated by rejection.

For others it was about possessing a unique skill set or perspective on life, "the way my mind works I've never known annihilation different…and considering of that I got treated different" (P7). Being able to deflect babyhood labels of deviance and learning to encompass their own uniqueness fostered a sense of wellbeing, merely was hard to achieve exterior the context of a supportive relationship. Women who felt validated by supportive intimate partners were better able to reverberate of their childhood experiences of exclusion and externalize the cause of this experience.

Doing It My Mode

This category was associated with increased confidence in one'due south experience and competence in mothering and signified a recovery milestone. Over time, women's self-awareness grew, and they became more insightful every bit to their own strengths, values and needs. This informed the resources and strategies they accessed to support their mental wellness and wellbeing. They gradually became proficient at seeking the support they required, whether that involved psychiatric medication, talking therapy, social connection, creating art, returning to study or if it was a viable economical selection, taking respite from employment.

A key recovery milestone was reached when women grew in confidence and self-belief, enabling them to recognize and confront people in their lives that they saw as exerting asymmetric influence. In relation to parenting choices and styles, four women spoke of rejecting the preferred methods of others and asserting themselves. A sense of empowerment emerged when they were able to exert control over their babe's wellbeing. For ane woman, ensuring that her own female parent was not verbally or physically violent toward her in her babe son's presence was of paramount importance, and she asserted herself around her expectations through threatening to withdraw access to her son.

Another participant reflected on receiving what she defined every bit a "one size fits all" (P5) approach to parenting and attributes much of her mental anguish to the circumstances of her adoption. Being able to successfully breast feed her baby for xviii months was an empowering experience for this mother, and perhaps the well-nigh powerful instance of her defying her adoptive female parent with great success for the health and wellbeing of herself and her son.

Living on her in-law's rural property, another woman (P2) explained how she withdrew from her married man's parents as a strategy to maintain her independence and to reduce the feelings of inadequacy her mother-in-constabulary instilled. In declining offers of child intendance from the children'south grandmother, this adult female sacrificed the potential for respite from her two immature children, in the interests of sustaining her demand for independence and autonomy.

Cocky-expression through choosing unusual clothing was how another participant asserted her own style. Creativity was employed to physical stand for her mood, and she shared how her curious outfits at times draw smiles from customs members, which and then made her experience "that little bit happier." On ane occasion she related dressing in a pink ball gown with a purple top hat to get to the supermarket:

"I only got upwardly feeling… I'm in a mood today, what tin I article of clothing? And I will spend hours because I demand to find (the right outfit) and I won't wear something that won't match my personality, if I don't I remember that matches my personality for today l won't habiliment it" (P7).

Speaking Out

The category of speaking out included disclosing, becoming a mental wellness advocate/educator, addressing stigma and challenging stereotypes. Although in speaking out, mental illness became ascendant in women's personal identity, it was viewed positively and enabled social identity through peer networks to flourish. Enduring the ups and downs of mental illness was seen as a valuable nugget that enabled women to have on an educator role, to connect with others through shared experience and to be knowledgeable in ways that others were not.

"My mental wellness journey has meant that I've got feel in that to be able to connect with people on that level and that'south what I want to be able to do" (P13).

Sometimes the desire to engage in community education stemmed from experiences of discrimination that woman believed arose from ignorance.

"I was angry with the way order treated u.s.a.. And just bandage us aside like we were zilch… you tin can't necessarily run into the pain that we carry with u.s.. Its soldiers. And that's what I call it. We're all soldiers. We're all in this together…" (P1).

When women began speaking out, they embraced their illness as a cadre component of self. The disease symptoms, treatments, and ramifications were integrated into their lives and were a part of how they viewed themselves and presented themselves to others:

"…doing the mental illness education was a really big office of my recovery so to go dorsum and give out to the customs, our point of view of how we experience, that'due south recovery likewise" (P1).

Participants expressed beingness selective in how and to whom they disclosed. Generally in that location was a correlation between the relative perceived prophylactic of the participant's social surround and the extent of their disclosing. Women who felt supported and who had a multi-faceted, secure and positive social identity within their customs were more likely to fully disclose. Past involvement with child protection was a deterrent that led women to muffle or minimize the impact of their mental illness.

Discussion

The majority of women who participated in this study described multifaceted identities that represented their mothering and familial roles, their employment or vocational occupations, customs relationships, hobbies and interests, religious and cultural condition likewise as the ways in which they defined their political or social values and attitudes. These descriptions encompass broader dimensions of identity than take previously been reported in studies with this accomplice (39). Each of these could be considered positive and socially valued, or negative and socially devalued, with implications for social and personal identity, depending on the perceived competence and autonomy in the role. For example, self-identifying every bit either a "good" or "bad" mother. Mothering was found to be a particularly powerful influence on women's self-concept, and participants identified the characteristics of being a "adept Mum" as cocky-sacrifice, being nowadays and enjoying the role. These concepts are congruent with the prevailing Western ideals of mothering that are grounded in traditional gendered roles that are oppressive to women (40). The findings emphasized the importance of identity to recovery, consistent with the CHIME framework (1).

Also meaning, were women's expectations of the future. Impending opportunities and obstacles were related to women's ideas near their own competence, social status, agency and aspirations. The findings likewise highlight that identity is inseparable from social connexion with participants described the ways in which their sense of self was heavily shaped by interactions with others (41). Effigy 1 represents conceptually the ways in which the women described the factors influencing their personal identity. This effigy was developed from the theoretical concepts that emerged from the data. Women described their identity being dependent on how they conceived their self-concept across a range of social domains. Each of these domains could be viewed as socially valued and positive or devalued and negative. Women spoke of being influenced not only past events and relationships from their past, but also their beliefs and aspirations regarding the future, thereby hope was a critical ingredient for a positive identity.

Figure 1. Influences on personal and social identity for mothers with mental illness.

The categories of "doing it my fashion" and "speaking out" were indicators of significant integration of the illness feel into a woman's personal and social identity. Although the illness identity was at the forefront in "speaking out," it was synthetic positively, intrinsically linked to meaning in life and empowerment, which are other recovery processes identified by Leamy et al. (ane). Women emphasized recovery outcomes attained through existence supported to identify their strengths, validate and normalize their challenges and self-reflect on the development of their identity across their life span. Often, however, prejudiced attitudes of others, specially associated with their mothering capacity, undermined women'due south self-concept.

Mothering Identity

Consistent with previous parenting studies [e.thou., (26)], participants spoke of disconnection from other mothers. This was associated with socio-economic science, parenting styles and difficulty infiltrating closed (well-established) social groups. Feeling asunder, socially isolated and "different" is a common experience for mothers with mental illness [east.g., (42)] and is considered a barrier to both sustaining a positive social identity and to recovery (43) and wellbeing more more often than not (41).

Identifying as a "good" mother was symbolic of women'south reflective capacity and internalization of social and cultural expectations equally they related to the morality of parenting and the quality of relationships to children. Narratives reflected how women compared their mothering experiences to archetypes represented in their social environment. This finding echoed Venkataraman and Ackerson's (44) study on sources of parenting norms in popular culture, the media and parenting literature. Importantly, the signals women perceived from service providers, portrayed a deep agreement of how society assesses "good" mothering, and an intense want to be viewed equally competent. This facet of personal identity was susceptible to women'south own internalized cocky-criticisms, in addition to the censorious messages conveyed past health professions or family members.

Having a psychiatric diagnosis was a cadre component of identity for some women, however this was not always experienced negatively, as disclosure could too bring meaning, purpose and connexion, when used to educate, support or advocate effectually mental affliction. For other women, having experienced mental health difficulties was just one relatively insignificant facet of a rich and varied life history. In this study a distinction between positive and negative identity was apparent, nevertheless this was not necessarily associated with the extent to which women embraced the illness equally part of their personal identity.

Identity, Mental Disease and Trauma

The information also parallels Agnew and colleagues' study that "highlighted the complex and intertwined nature of traumatic experience, personality organization, and self/identity" [(19), p. eight]. Crucially important in defining a self-concept within the current report, were women's experiences from the past, including trauma resulting from physical, psychological or sexual abuse, the quality of early on life attachments, transience in housing and schooling, relationships with siblings and parents, experiences at school and access to physical and economic resources. These factors, along with the ways in which women anticipate them have besides been previously highlighted (32, 42, 45, 46). In this written report, these factors shaped the identity journey and the mode the women saw themselves in the present.

For some women, having a diagnosis provided meaning and understanding that made sense of their symptomatic experiences. Additionally, this enabled them to connect with a peer network of others who shared like thoughts, feelings and behavior and this offered validation. Mental health education and activism constituted a positive estimation of lived experience that could simultaneously maintain the mental disease part of identity at the forefront.

Identity and Change

Identity is assumed to be fluid and dynamic within self-categorization theory (7), and while the participant interviews in this written report are a snapshot in time, identity was described by participants as flexible, changing and evolving. This was evident in women'south descriptions of themselves over time, and the ways in which they connected with others including disconnecting from unhealthy relationships and becoming more discerning or alternatively, learning to trust. However, there was as well reference to consistent and indelible components of identity associated with preferences and strategies for managing stress and mental wellness difficulties. Crossley (47) adopted a narrative approach in investigating the confusing impact of trauma, identifying the capacity for trauma to unseat previously coherent conceptualizations associated with self. Crossley (47) establish that assumptions regarding one's usual patterns of thoughts, behavior and emotions are undermined forth with i'due south temporal awareness that ordinarily provides meaning and context. This is coinciding with women's descriptions of managing distress, in the early period of the illness. For the participants in Crossley'south written report, narratives go prominent in creating significant, when customary psychological processes fail under the vast strain of traumatic occurrence.

Non only was it observed that events from women's past shaped their current identity, but their perceptions of their hereafter lives including hopes, plans and aspirations were also influential in defining how they perceived themselves in the nowadays. Identity evolution appeared to be a non-linear process that was highly permeable to social influence.

Recommendations for Research, Policy and Exercise

The findings demonstrate mothering identity to be important for mental illness treatment and recovery. Women primarily related as mothers in articulating their self-concept and strove to exist recognized as proficient in this part, highlighting their skills, strengths and underpinning parenting values as critical components of their identity. Therapeutic interventions need to explore mothering relationship to cocky and others, every bit "therapeutic understanding that takes into account the deficiencies within diagnostic criteria and acknowledges the various nature of self and identity of an individual may meliorate the therapeutic relationship" (19). Within such interventions, women need to feel safe and secure to explore their identity "journey" including the interactions and events that have led to their current self-concept.

A strong therapeutic brotherhood is critical to cultivating a safe space within which women can begin to accost the issues that underpin their healing and recovery (48). Women spoke of the importance of this particularly in the early on parenting phase, while adjusting to a new mothering role, and not yet feeling confident in their parenting cognition and skills. The women who participated in this study indicated that validation of normalcy of parenting challenges can be useful at this time, as well as a more conversational approach that moves beyond the cess checklists, to the development of an accurate relationship that offered individualized support, rather than reinforcing a sense of being "monitored" and judged.

Elevating the significance of identity and self may reveal areas of intervention that tin can support more flexible, nuanced and realistic expectations surrounding women'south multiple roles and activities. Identity work, integrating past experiences that may challenge individual'due south assumptions regarding their identity (43) and reflecting on emotional and behavioral responses, is best-selling equally a cadre component of the recovery process (1, 48).

Beyond this, the electric current inquiry suggests that investigation of identity and cocky in the context of social and environmental conditions must contain critical reflection on the dominant norms that may exist oppressive and result in devalued status within various identity domains. Challenging and contextualizing these dominant assumptions may exist particularly significant for marginalized population groups (e.g., Indigenous, people identifying as GLBTI), who are demonstrated to be at increased risk of developing mental health difficulties (49).

Discussions at this deeper conceptual level may be perceived as challenging to establish in the midst of psychological distress, and practitioner judgment in ascertaining readiness for such discussions is essential. However, avoiding these topics can pathologise individual responses to issues that are associated with layers of structural inequality. Hereafter enquiry should likewise focus upon overcoming workforce barriers inside mental health and family services to engaging in identity work with women who have a mental illness.

Mental health policy needs to recognize and reverberate the importance of identity work every bit a crucial part of do. A disproportionate focus on medication and take a chance management within clinical mental health continues to stifle recovery oriented practice that encompasses a holistic view of people including consideration of their diverse and multi-faceted roles and relationships.

Conclusion

The importance of developing and sustaining an identity that is multifaceted and socially valued has been under-best-selling within mental health services, despite positive identity evolution being repeatedly identified as a fundamental feature of the recovery process. Fostering a positive cocky-concept, particularly associated with 1's parenting part, can help in facilitating personal recovery in mental illness.

For women who are mothers with mental affliction, gendered norms around the mothering function can effect in the imposition of unrealistic expectations of women'southward functioning, particularly if they are living in impoverished social and economic circumstances. Identity work needs to incorporate consideration of the personal level including past experiences, relationships, thoughts, emotions and beliefs, also as the broader ecology context.

Ethics Statement

This written report was carried out in accordance with the recommendations of the Australian National Statement on Ethical Behave in Human being Research. The protocol was approved by South W Healthcare Multi-disciplinary HREC, Monash University HREC and Ballarat Health Services and St John of God Hospital HREC. All subjects gave written informed consent in accordance with the Annunciation of Helsinki.

Author Contributions

RH, DM, and MG developed the enquiry design and methodology together. RH undertook the literature review and the information drove and led data analysis. DM and MG contributed to data analysis and all researchers were involved in initial coding and conceptual analysis likewise every bit developing the findings. RH wrote the manuscript with editing/contributions from DM and MG.

Disharmonize of Involvement Statement

The authors declare that the research was conducted in the absenteeism of any commercial or financial relationships that could exist construed every bit a potential conflict of involvement.

Supplementary Material

The Supplementary Material for this article tin exist institute online at: https://www.frontiersin.org/manufactures/10.3389/fpsyt.2019.00089/full#supplementary-textile

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