Postnatal Counselling: Early Intervention for Mothers with Postnatal Depression, MumsAid CiC, Royal Borough of Greenwich

Themes this local practice example relates to:

  • Early Years
  • General resources
  • Local area early intervention strategies

Basic details

Organisation submitting example

MumsAid Community Interest Company (CiC)

Local authority/local area:

Royal Borough of Greenwich


The context and rationale

An early intervention counselling service to ameliorate the impact of postnatal depression on the family,offering a range of evidenced based approaches rather than one fixed model. Adapted to individual need the service addresses a broad spectrum of emotional difficulties that may be experienced during the perinatal period.

Aims

•To provide an inclusive and accessible intervention for mothers with postnatal depression (PND) that would reach women who might not usually take up therapeutic support.
•To alleviate postnatal depression and thus reduce the potential negative impact on the development of babies’ emotional, cognitive and social development in at least 10 families.
•To improve the bond between mothers and their babies.
•To improve the mother’s confidence in her parenting ability.

Background
There were over 5000 registered births during 2011 in the Royal Borough of Greenwich (1) and with postnatal depression (PND) affecting an estimated 1 in 5 new mothers (2)this poses a significant challenge to maternal mental healthcare provision in the borough. An ever-growing body of research illustrates the link between maternal mental health difficulties and poorer developmental outcomes for babies’ emotional, social, cognitive and linguistic abilities (3). In addition it has been shown that women with PND are seven times more likely to experience relationship problems (4). 

‘Talking therapy’ is recommended by the NICE guidelines as a ‘first choice’ treatment option for women where they have mild to moderate postnatal depression (5. The aim of this service was to alleviate the symptoms of mothers who were experiencing PND, particularly amongst those who might not generally take up ‘talking therapies’ and in so doing reduce the negative impact on their families.

This intervention evolved from a parenting project funded by the Department for Education (DfE) ‘Parenting Fund’ between 2006 and March 2011 that had initially been managed by Greenwich Mind and the Tavistock Centre for Couple Relationships. That service illustrated both the demand for PND specific support and the benefits of locating such services in a children’s centre (6). The Royal Borough of Greenwich Children's Services (Integrated Support Children and Families) supported the service to be developed by Miriam Donaghy, the originator of that Project, and founder of MumsAid CiC (Community Interest Company) a non-profit organisation set up ‘to meet the challenges of postnatal depression’. 

Interpersonal Psychotherapy (IPT) has the best evidence base for a ‘talking therapy’ for PND, with its efficacy demonstrated through a number of randomised control trials (7). Building on what had been learned in the previous provision of PND counselling it was decided to use an IPT model but to adapt when necessary so that a flexible talking therapy that could address the needs of women with a range of PND symptoms could be supported. A key focus of the intervention was being ‘family centred’ (offering a crèche, and being aware of the child’s as well as the mother’s needs). In addition, given our understanding that social disadvantage greatly exacerbates the difficulties that postnatal mothers experience, rather than exclude clients where their primary difficulties could not be shown to be psychological (as some talking therapy services do) it was the intention that this intervention would be open to any mother ‘struggling’ regardless of the causation. 

(1) ONS PH Birth Files, Jan 2011 - Feb 2012
(2) Royal College of Nursing (2007)
(3) Smith 2011, Huang et al 2006, Murray, L 1992
(4) Kung (2000) Journal of Marital Therapy Journal 26 (1) 251- 63
(5) National Institute of Clinical Excellence guidelines (2007)
(6) Clulow, C Donaghy M, ‘Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families’ in Journal of Family Therapy Issue 32 May 2010
(7) O’Hara, Stuart, Gorman (2000) Archive of Gen Psychiatry 57:1038-45 

The practice

The service was delivered at Brookhill and Storkway Children’s Centres in The Royal Borough of Greenwich. It was initially piloted for seven months. Five sessions were offered each week, and mothers were initially seen on a weekly basis. Once the counselling relationship was established and providing the mother was not in crisis, sessions were often spaced out at longer intervals as the counselling progressed. Each mother was able to attend up to 12 sessions. A follow-up session was offered if it was felt necessary to maintain some support. Operating in this way meant that the service could ‘hold’ more than five mothers at one time and also enabled time on the waiting list to be kept down.

The counselling was provided by a perinatal Psychotherapist from MumsAid, with more than 13 years’ experience of providing postnatal support both to individuals and groups, as well as experience in training professionals in PND awareness.

The service was provided in two children’s centres, where an established and active partnership between the psychotherapist and centre staff meant that cross referrals between the postnatal counselling and other services in the centres could easily take place. Health visitors involved with each of the centres were invited to make referrals. 

Those wishing to refer, which also included GPs, completed a simple referral form with the client’s and baby’s details and reason for referral. This was emailed directly to the psychotherapist, who then made contact, firstly with the referrer to discuss if there were any particular concerns or safeguarding issues, and then with the mother. The initial contact with the mother was by telephone rather than letter, and she was asked whether the counselling was something that she was interested in. If the answer was positive, she was offered an appointment within two weeks for an assessment.

During that appointment the mother was given the pre-intervention questionnaire to complete, and the process of counselling was explained to her as were the requirements for the crèche. (Mothers who wished to use the crèche were required to attend a minimum of two settling in visits with their baby). The nature of the mother’s difficulty was also assessed and whether it would be helpful for her to attend sessions with or without her baby. 

The mother then attended up to a further 11 sessions of counselling based on an IPT model of intervention with an established focus for the work agreed between the therapist and mother during the early sessions. 

During the middle phase the counselling continued with a pragmatic here and now approach, which included psycho-education about PND, attachment needs of the baby, and normalising the difficulties of the transition to becoming a parent. In addition, the counselling aimed to set up a broader support network and explored whether medication help might also be requested from the GP if desired and or required. 

In the final phase there was a consideration of how to maintain improvement, the next steps to access other support/services available for both the mother and baby, particularly considering what could be accessed in the children’s centres being attended. In the twelfth and final session of the intervention the mother was asked to complete a post-service questionnaire and was offered the option of a follow-up appointment for three months later.

Evidence and evaluation - making a difference to children, young people and families

Evaluation
An evaluation of the service was carried out using information gathered by pre and post service questionnaires. Measures used to assess outcomes included the Edinburgh Postnatal Depression Scale and a shortened version of the Relationships Dynamics Scale (RDS) measuring mental health improvement outcomes in mothers; and relationship quality with their partners. 

In addition, the questionnaires included self-report scales to determine the bond between mothers and their babies, and their experienced levels of stress and confidence in parenting their babies. As well as the measures, the pre-service questionnaire included a section that asked for demographic information including race, age, marital status, post-code, number of children and whether they were receiving other support for their present difficulties (including medication). All those who received counselling were also asked to complete a satisfaction survey rating their experience of the service they received. 

In summary, the postnatal counselling service was successful both in terms of meeting the targets for the numbers of women seen, and in terms of ‘outcomes’ which have indicated significant improvements for the mothers in all categories measured. Further details are shown below and a copy of the evaluation is available from the C4EO team at C4EO team at the NFER 

The results have been particularly pleasing in the improvements achieved in the mother’s levels of depression, especially given that many of these mothers had multiple and complex difficulties affecting their mental health. Service user feedback in the service received was also consistently very high.

On the Edinburgh Postnatal Depression Scale there were several positive points to note: 

• The individual score improved for all mothers who had completed counselling. 
• The mean score fell from 19.2 on the pre-service questionnaire to 10.8 on the post-service questionnaire. 
• All but one of the mothers had moved to below the depression threshold of 11. 

In addition, looking specifically at the data for question 10 which asks about thoughts of suicide or self-harm, three mothers had answered positively to this being a risk in the pre-service questionnaire but in the post-service questionnaire this was identified as a continued risk for only one mother. The data allows us to see that this is the same mother who was also still above the depression threshold in the overall scoring, and there are specific factors to explain why this is the case(8). 

PND may have an impact on the quality of the bond between a mother and her baby both implicitly and explicitly, but only one mother identified this as an explicit issue in the pre-service questionnaire. Her score in the post-service questionnaire had greatly improved indicating that she had resolved her ambivalent feelings about her baby at the end of her counselling.

For all mothers who identified confidence in their parenting as an issue in the pre-service questionnaire, there was a marked improvement in their post-service questionnaire.

The stress score which asked about how stressful the mother found the experience of parenting was measured on a scale of 1-5, with 5 being the highest. This improved for all but one mother in the post-service questionnaire and the overall mean score decreased from 2.7 to 1.8.

As well as improved outcomes, the pilot was also successful in its target of reaching women whom might not normally take up services. It was an ethnically and socially diverse group and there were many mothers with complex and multiple difficulties including families who were already subject to child protection plans and Team Around the Child plans(TACs).

(8) This mother has immigration issues and other life difficulties that make it hard for her depression to be resolved. She has however shown some improvement, moving from a very high score of 26 to 19 on the EPDS.

Helping others to replicate your practice

Sustaining the Service
In order to continue delivering and extending the service to meet the huge demand, MumsAid has developed the service so that trained, experienced counsellors will work as volunteers, overseen and supervised by a senior Perinatal Psychotherapist. This allows for a cost-effective roll-out and extension of the current provision.

Costings
Overall cost for 7 months working with 14 families was £8,568.
Cost per family £ 612.

A cost benefits analysis is not available at this stage but given the statement from C4EO’s golden thread that ‘effective intervention early in a child’s life yields the greatest results and saves a great deal of costly investment later on’ it is envisaged that the benefits versus cost of this successful intervention are considerable.

Learnings
Postnatal depression covers a multitude of difficulties and the current recommended ‘evidenced’ based approaches are often suitable to one client group and not another.This service should be managed by someone knowledgeable about the variations of perinatal mood disorders who can then assess and allocate to a counsellor with the appropriate skills to deliver for example, Interpersonal Therapy for depression, Cognitive Behavioural Therapyinformed approach for more anxiety based disorders and Eye Movement Desensitisation and Reprocessing for those with Post-Traumatic Stress Disorder. For all, a knowledge of how to support the mother-baby relationship is essential . 

It is also important to have good links with local services and other agencies so that the support doesn’t have to end after a relatively short term of counselling. Thought should be given to follow up support from the beginning.

Although the intervention is described as postnatal counselling, the criteria are for women with a baby up to the age of two years, as experience of delivering this service has taught that many women suffer in silence for many months, sometimes longer, before getting help. 

C4EO Golden Threads
The golden threads that apply to this example are:

• Ensuring the best start in life - effective intervention early in a child’s life yields the greatest results and saves a great deal of costly investment later on.

• Language for life - there is a strong correlation between communication, attainment, mental health problems, poor employment and youth crime.

There is a great deal of evidence about the links between a child’s cognitive and linguistic skills being adversely affected when mothers have PND - for a summary see (9). In having a positive impact on the mother’s PND, it is clear that this intervention is effective in the golden threads identified above.

(9) Donaghy, M ‘Postnatal Depression and the Impact on Child Development’ Parenting UK issue 33 Dec 2011

Replication
The service can and should be replicated as there is a huge need for tailored support for mothers with PND.It is essential however, that it is headed up by someone with a good knowledge of perinatal mood disorders, and treatment approaches as well as previous experience of working with this client group.It is vital for example that there is awareness about identifying more severe types of perinatal difficulties such as puerperal psychosis.It is also essential that other counsellors in the team receive training around PND awareness and ongoing supervision with someone with appropriate and sufficient experience.

Core Leadership Behaviours
Eight core behaviours have been identified as part of successful elements of leadership (see National College for Leadership of Schools and Children’s Services/C4EO (2011). Resourceful leadership: how directors of children’s services improve outcomes for children. Full report. Nottingham: NCSL.

Those applying to this example are:

Demonstrating a belief in team and people
A belief in the families and their potential to improve as well as a belief in the team of counsellors who have worked in the service, that they can make a difference.

Personal resilience and tenacity
Working with this client group where there were multiple and complex needs required the ability and knowledge to look after one’s own emotional health and the process of engagement with clients who had been resistant to many other service required a lot of tenacity. 

The ability to create and sustain commitment across a system
To make the counselling work meant having good relationships within the centres, with support from crèche staff and others as well as from a wide spectrum of referrers.

Focusing on results
Having improvement of the mother’s mental health, as well as improvement of the outlook for her baby, as the focus was always central and led to the service being adapted to meet this end.

The ability to learn continuously
Important not only for keeping up to date with best therapeutic practice and what the science is saying about impact of PND, but also in terms of always trying to learn and improve about new ways to measure impact.

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