Organisation submitting example
Local authority/local area:
Royal London Borough of Greenwich
An inclusive and accessible one to one counselling intervention for mothers experiencing a broad spectrum of perinatal mood disorders during pregnancy or postnatally that aims to reach women who might not usually take up psychological support services.
1. Context and Rationale
Birth rates in the Royal Borough of Greenwich (RBG) rose by almost 40% in the ten years preceding 2011 to over 4500 that year, and with prevalence rates for major and minor depression reaching almost 20 per cent during pregnancy and the first three months after childbirth there is 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.
Maternal stress, anxiety and depression in pregnancy for example, are associated with adverse foetal and neonatal outcomes ; perinatal anxiety and depression have been shown to have a deleterious effect on developing maternal-foetal attachment; and anxiety and depression may influence a parent’s capacity to care for their baby, as the ability to be emotionally available and attuned to the infant can be impaired.
Furthermore, these factors can potentially have long-lasting results for infant outcomes, which have been found to extend into adolescence and beyond.
This intervention evolved from a parenting project funded by the DfE ‘Parenting Fund’ that had been managed by Greenwich Mind and the Tavistock Centre for Couple Relationships between 2006 and March 2011. That service had illustrated both the demand for postnatal depression (PND) specific support in the borough and the benefits of locating such services in a children’s centre.
When the funding ceased, RBG’s Children's Services supported a pilot Postnatal Counselling service to be developed by Miriam Donaghy, the originator of that Parenting Project. When the pilot which was awarded promising practice by C4EO was also successful it led to the establishment of MumsAid, a non-profit organisation set up to provide perinatal mental health support and to extend the therapeutic counselling that had been offered by the pilot.
‘Talking therapy’ is recommended by the NICE guidelines as a ‘first choice’ treatment option for women where they have mild to moderate postnatal depression . The aim of the pilot service was to alleviate the symptoms of mothers who were experiencing postnatal depression (PND), particularly amongst those who might not generally take up ‘talking therapies’ and in so doing reduce the negative impact on their families and in particular their babies. However, with the setting up of MumsAid, it was decided to extend the offer of a service to those who were experiencing emotional difficulties during pregnancy as well as postnatally.
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 . 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 maternal mental health needs would be offered. The therapist would also incorporate a mentalisation based approach supporting mothers to respond sensitively to their baby enabling the formation of a healthy relationship.
Key to the intervention was that it was to be ‘family centred’ (offering a creche, and aware of the child’s needs as well as the mother’s). In addition, given our understanding that social disadvantage greatly exacerbates the difficulties that women in the transition to motherhood experience, it was the intention that this intervention would aim to reach out to women who might not usually access psychological support and be open to any mother ‘struggling’ regardless of the causation.
Aims of the project
• To provide an inclusive and accessible one to one counselling intervention for mothers experiencing a broad spectrum of perinatal mood disorders during pregnancy or postnatally that would reach women who might not usually take up psychological support services.
• To alleviate perinatal mental health difficulties including antenatal and postnatal depression and anxiety, and thus reduce the potential negative impact on the development of babies emotional cognitive and social development.
• To improve the bond between mothers and their babies.
• To improve the mother’s confidence in her parenting ability.
2. The practice
The service was provided initially in two Children’s Centres and later in four, Brookhill, Mulgrave, Robert Owen and Storkway, where an established and active partnership with centre staff meant they made appropriate referrals. Two to three sessions were offered each week at each centre and mothers were initially seen on a weekly basis. Once the counselling relationship was established with the mother and providing she was not in crisis, sessions were often spaced out at longer intervals as the counselling progressed. Each mother was able to attend for up to 12 sessions.
A follow-up session was offered at three months after the 12th session and as the service evolved a second follow up was offered at six months after the final session. Operating in this way meant that the service could ‘hold’ more mothers at one time and also enabled time on the waiting list to be kept down. It also allowed us to track whether the improvements being made were being sustained.
The counselling was provided by the clinical director of MumsAid, with more than 16 years’ experience of providing postnatal support both to individuals and groups, and four additional volunteer counsellors who had completed substantial psychotherapy training courses and had previous experience of this client group, closely supervised by the clinical director.
Volunteers are recruited through a number of avenues, and we are increasingly approached by therapists who have an interest in the work and want to gain experience where they know they will be supported through supervision and other like-minded individuals. When we advertise we do so on the BACP online site for those looking for placements and also through organisations and networks where people have chosen to train because they are interested in this perinatal and early intervention work. We ask for a minimum 18 month commitment at interview from volunteers.
We also had a Trustee Board that included two very experienced psychotherapists and a psychiatric nurse who had been awarded ‘Nurse of the Year’ in 2010 for her work in promoting perinatal mental health.
In addition, health visitors who are involved with each of the centres make referrals and we receive an increasing number of self-referrals (16%) due to our active online presence.
Those wishing to refer, which also included GPs, self-referrers, a psychiatric nurse CAMHS workers and others completed a simple referral form with the client’s and baby’s details and reason for referral, plus GP and health visitor contact details. On receipt of the form, the MumsAid’s administrator 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 and about her requirements for the crèche. (Mothers who wished to use the creche were required to attend a minimum of two settling in visits with their baby). If we were unable to offer an appointment for an assessment within two weeks, which we mostly aimed to do, the mother was offered the option of receiving weekly telephone support, told about our social media and signposted to other helplines that could be used in the meantime.
At the first appointment the mother was given the pre-intervention questionnaire to complete, and the process of counselling was explained to her. 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 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 of the difficulties of the transition to becoming a parent.
The mother was also supported to ‘mentalise’ (sometimes known as a mind-mindedness approach) on the experience of her baby encouraging the development of a sensitive, reflective relationship with the infant to promote bonding and strengthen the parent-infant relationship. In addition, the counselling aimed to set up a broader support network and to explore 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 3 months later.
One year into the project it was felt that it would be helpful to offer a second follow up appointment at 6 months. At both follow-ups the mother was asked to complete the post questionnaire again.
3. Evidence and evaluation - making a difference to children, young people and families
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 (EPDS), the Perceived Stress Index (PSI) 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 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.
The evaluation showed that the counselling service was successful both in terms of meeting the targets for the numbers of women seen from harder to reach client groups, and in terms of ‘outcomes’ which have indicated significant improvements for the mothers in all categories measured including their mental well-being.
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 and we have also seen significant improvements in bonding and attachment. Service user feedback in the service received was also consistently very high as is feedback from referrers.
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 18.02 on the pre-service questionnaire to 9.05 on the post-service questionnaire
• 85% had moved to below the depression threshold of 11
Bonding and attachment issues are not present for all mothers with perinatal mood disorders but for those mothers for whom bonding difficulties were identified as an issue at the start of counselling, 61.5% reported either that this was no longer the case or that there had been considerable improvement in their post-service questionnaire. Likewise, 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 PSI results which measured the degree to which situations are appraised as stressful and how unpredictable, and overloaded respondents are feeling also showed improvement, with the mean score decreasing from 25.35 to 18.30.
Follow up data
We were interested to see if improvements would be maintained at the follow up sessions at three and six months after counselling, and so the post-service questionnaire was given again at these appointments. For the 10 women who have had both follow up appointments to date, the data has been encouraging with sustained improvements, and in two cases further improvement in depression scores, so that the mean score for the EPDS had decreased to 7.2 at the first follow up and then to 4.9 at the second follow up. On the PSI the mean score had also reduced slightly to 17.
As well as improved outcomes, MumsAid has been successful in its target of reaching women whom might not normally take up services. The women who received a service were from an ethnically and socially diverse group, 50.8% of women attending were not White British and there were many mothers with complex and multiple difficulties including families who were already subject to child protection plans and TACs.
4. Sustaining and replicating 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 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. We have also sought to achieve diverse funding streams, from charities including CityBridge Trust, who funded our collaborative peer support project with Greenwich Homestart, and from Children in Need who has just awarded us two years of funding to extend our offer to teenage mothers and mothers to be.
There have been two big challenges in developing and sustaining our service. The first has been around trying to get the need for services for perinatal mental health seen as a priority that should be properly funded, though this has been helped greatly more recently through the work of the MMHA, Wave Trust and others, and the national publicity that has received. The other challenge has been to have a voice as a third sector organisation. There continues to be an assumption that third sector organisations cannot hold the expertise that they often do, and as a result there are additional barriers to getting recognition and funding from clinical commissioning groups (CCGs) that statutory services do not seem to face to the same degree.
Overall cost for the counselling service was £20,000 per year. This however, did not represent full cost recovery as it was based on a reliance on volunteers with initially only one paid part/time clinician, providing clinical supervision as well as recruitment and management of all the volunteers. The project has been hugely subsidised by the therapists working for free, the Clinical Director being paid for only a day and a half per week, whilst working many more hours than that, and the administration also being carried out by a volunteer. In addition, our branding, website and technical support have all been provided pro bono.
We do not have a cost benefits analysis available at this stage but are currently working on one based on ‘The Costs of Perinatal Mental Health Problems ‘ an economic report detailing the cost of untreated perinatal mental health which showed that nearly three-quarters (72%) of the cost relates to adverse impacts on the child rather than the mother. We also tend to draw on the newly released ‘Building Great Britons report’. Both these reports make the case that early intervention yields the greatest results and saves a great deal of costly investment later on, and so it is envisaged that the benefits versus cost of this successful intervention are considerable.
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 needs to be managed by someone knowledgeable about the variations of perinatal mood disorders so that they are able to assess and allocate to a counsellor with the appropriate skills to deliver for example, interpersonal therapy (IPT) for depression, cognitive behavioural therapy (CBT) informed approaches for more anxiety based disorders and EMDR for those with post-traumatic stress disorder.
For all, a knowledge of how to support the mother-baby relationship is essential as well as an understanding of the more rare psychiatric condition of puerperal psychosis so that relevant medical support is requested when needed, and appropriate referrals made to GPs and home treatment teams etc.
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.
We support women with babies up to two years old, as experience of delivering this service has taught us that many women suffer in silence for many months, sometimes longer before getting help.
We have started our new Teen mothers project with a steering group consisting of very experienced and multi-disciplinary practitioners as we have learned the importance of building a good exit strategy for mothers from the start and also how collaborative working can mean increased effectiveness.
We believe that this service meets the following Golden Threads identified by C4EO :
You can do it - promoting resilience by improving the safety, health and wellbeing of children through improving the physical and mental health of mothers, fathers and carers.
Culture not structure - Learning together
We are very keen on promoting a culture of collaboration with children’s centres, health visitors and other services that are also aiming to improve children’s outcomes by supporting parental relationships
Unite to succeed - The right support at the right time and flexible services that can respond to individual need are shown to be most effective. At every step our service has been designed with the mother and baby in mind and flexibility is the cornerstone of what we do. We prioritise providing a service that doesn’t involve long waiting lists and we consider what other support can be offered, i.e. by telephone, online, and peer support for anyone who might have to wait for an assessment.
Prove it - Making change happen - We take a very pro-active approach to engaging with the evidence around what works and are also very keen on gathering our own data with regular reviews to consider new ‘measures’ and how we can make improvements.
The service can and should be replicated as there is a huge need for tailored support for mothers with Perinatal mental health issues. 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.
It is helpful to have other back-up services to offer such as peer support or telephone counselling for those who are not ready to take up counselling or may not be able to access an immediate appointment.
t. 020 7833 6825
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