Listening Visits in Perinatal Mental Health

A Guide for Health Professionals and Support Workers

Jane Hanley

• Publisher: Taylor & Francis
• Year: 2015
• eBook ISBN: 9781317683773
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Listening Visits in Perinatal Mental Health focuses on how women and families suffering from perinatal mental illness can be supported by a wide range of practitioners. Based on the skills of attentive listening, it is designed for use by health professionals and support workers concerned with maternal mental health and the mental health of the family.

This accessible guide:

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• Covers the process and progression of perinatal mental health
• Discusses the types of anxiety and depression which may occur during the perinatal period
• Examines the impact of maternal mental illness of the infant, father and family
• Explores the available assessment tools, such as the EPDS
• Presents the theories behind the efficacy of listening and counselling skills, as well as the evidence which recommends this type of therapy
• Gives suggestions of alternative therapeutic approaches and further resources to explore around perinatal mental health
• Emphasises the importance of looking after yourself and making use of supervision and peer support.

With chapters focused on listening to mothers, fathers and infants and paying attention to cultural diversity, Listening Visits in Perinatal Mental Health builds on the knowledge that many professionals working with new mothers already have about perinatal mental health. It focuses on developing the skills needed to put this knowledge into practice and includes case examples and follow-up activities throughout.

1
The Importance of Good Perinatal Mental Health

‘Perinatal mental health holds the key to unlock the mystery of mental health – we just have to locate it’

(Professor John Cox, conversation with author)

Introduction

Postnatal depression was a condition which concerned health professionals over ten years ago. It was recognised by society as a disabling and distressing problem which occurred to the mother following the birth of her baby. It was more severe than the baby blues and lasted longer. Some health visitors knew what to do, often general practitioners were consulted and sometimes psychiatrists and community psychiatric nurses became involved in the care of the mother. In some parts of the country there were mother and baby units which housed the mother with her infant, while the mother was being treated for severe depression or psychosis. Both were able to remain there until the mother was able to cope with her illness and was subsequently discharged. Care in the community was variable across the country, with no significant randomised control studies to support or negate the efficacy of the support networks. The services provided the best care they could.

Anecdotal reports suggested that many mothers, concerned about the severity the impact of their illness had, not only on them and ultimately their family, made a conscious decision not to have any more children. Had a mother made a similar decision following the advent of a physical illness, there would have been an outcry from society which would have ensured that science made a concerted effort to find a cure.

We have come a long way since then … or have we? From a research point of view there have been radical and groundbreaking studies on the identification of depression as an illness. Other mental or psychiatric disorders have been identified, to include stress, generalised anxiety disorder, eating disorder, obsessive compulsive disorder, bipolar disorder, puerperal psychosis and schizophrenic disorders, which are known to have some effect on the unborn baby and the infant. There is currently more knowledge around the effect perinatal mental illness – the overarching term which describes conception to one year following the birth of the baby – has on infant and child development, the relationship with the father and the ultimate impact on society.

Importance for the Foetus

Once revered, it is now disputed that pregnancy holds the same credibility, respect and esteem within society as it did in the past. Modern day living, coupled with the need for financial stability, has forced many mothers to work until late into the third trimester of pregnancy, and to resume working shortly following the birth of their infants, allowing little room for respite. It is important to recognise the conditions that can be deleterious to a mother’s mental health and have an awareness of the therapeutic and practical interventions designed to reduce stress and anxiety during her pregnancy. Good maternal mental health in the antenatal period will have a positive effect on the foetus and ultimately the infant, and should reduce any problems with the physical, cognitive, behavioural and emotional development which may have an effect on the child in later life and adulthood (Talge et al. 2007). To summarise, it is critically important to the foetus to maximise the mother’s overall mental and physical health in pregnancy and after childbirth.

Importance for the Mother

Postnatal depression affects one in seven mothers (Wisner et al. 2012); this is an increase on the numbers given in the seminal work of Cox et al. (1987) over 25 years ago, which found that one in ten mothers were suffering from the illness. Overwhelming evidence during this time span has suggested that mothers suffering from depression in the antenatal period are more predisposed to have a depressive disorder in the postnatal period (Evans et al. 2001, Pawlby et al. 2008). The symptoms of depression however are no more common or severe after childbirth than during pregnancy, although they are usually more conspicuous after childbirth because there is considerable focus on the mother and baby.

The philosophical arguments about postnatal depression being regarded as a psychological state, as opposed to the continuum of mental well-being, remain unclear. Although it is recognised as being specifically linked to the advent of childbirth, often it is argued that it is difficult to distinguish the condition from the diagnostic measures for a normal depression, as reflected in the Fifth American Diagnostic and Statistical Manual of Mental Disorders (DSMV 2013). Nevertheless whatever the arguments, perinatal mental illness continues to be a challenge for mothers and their families (Goodman & Tyer-Viola 2010). There are numerous reasons why it is important to recognise and treat antenatal depression as studies have found several risk factors for antenatal depression which have been linked to poor outcomes for the infant, including prematurity and low birth weight (Shivakumar et al. 2010, Alderdice et al. 2012).

Importance for the Father

Men whose partners were depressed postnatally found the experience overwhelming, frustrating and stigmatising; overwhelming, because when faced with the plethora of the dispersive depressive symptoms, men often found they were unable to understand the insidious process of maternal depression which intruded into their life and that of their family (Conde et al. 2011, Gilligan et al. 2011). In one study Simmonds et al. (2014) found that almost a quarter of fathers experienced a mental health problem for the first time during their partner’s pregnancy. The transition to fatherhood can be a time of risk for significant mental health problems. This is of interest, particularly if the father has a prior history of anxiety, which can be an indicator for antenatal depression.

Importance for the Infant

It is not difficult to understand that if the mother’s emotions are in a state of flux, she would find it difficult to bond with her infant. The word ‘bond’ has powerful connotations and presupposes that the mother has a strong maternal attachment to her baby; however this is not always the case. A mother who has experienced stress or depression during her pregnancy may often admit to neutral or even negative feelings. Whereas these may be common feelings, for some mothers, this may cause guilt, resulting in anguish, which only serves to exacerbate her feelings. This inability to express warmth and love might be unintentionally replaced with irritation and anger, not only towards her self but her infant. The necessary conditions for survival may be com promised, not physically, but emotionally. To secure positive development for the infant, it is important to provide the prerequisites of warmth, sustenance and love. All of this can be achieved by the mother who is mentally well, but can be negated by the mother who lacks those fundamental requirements in her own life. The long-term consequences have been evaluated and it has been found that there may be penalties for the older child as their development, cognitive functioning and behaviour may continue to be affected.

Importance for Society

The World Health Organisation (1984) states that: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. The body of evidence currently presented clearly points to the impact on the infant’s development which is determined by all of the attributes contained in that statement. This, in turn, will have a significant influence on the social determinants and the ultimate health of society.

There is increasing evidence that as the values and structure of society change and fragment, it loses the more traditional aspects of maternal and childcare. Therefore the need for good mental health should be a priority not only for local communities but for the whole of society. More importantly the recognition and management of deteriorating maternal mental health should be crucial to prevent serious consequences for the mother and her family.

Improving access to interventions either with psycho-pharmaceutical medication or interpersonal therapies, should be high on the public health agenda, and research into alleviating the causes of mental illness and efficacy of medication and treatments, a priority. If equal consideration were afforded to mental illness as it is to physical illness, a cure or at least a reduction in symptoms would be imminent. We owe it to future generations to ensure that there is a well managed perinatal mental health service, for if we are searching for a key to unlock the mysteries of mental illness then surely the place to start is at the beginning of life itself.

Perinatal Mental Health

Antenatal period

Women are at increased risk of mental illness during the perinatal period, and both perinatal mental illness and the treatment for these conditions may have long-term implications for their infants.

Anxiety

Anxiety is a common and understandable feature in perinatal mood disorders, but it is important to distinguish between what is a relatively mild anxiety or worry, and that which might indicate a more severe underlying mental health problem. Anxiety and stress is usually characterised by excessive worry, but it is difficult to control and causes significant distress. Common features are restlessness, irritability, constant tenseness and weariness. Concentration is problematic and the sleep pattern is often disturbed. The symptoms are usually experienced on more days than they are not.

Hyperemesis gravidarum (HG) may be a predictor of increased anxiety during pregnancy (Martin 2012). While an association between HG and mental illness seems likely, Kim (2009) found there is currently insufficient literature to support this link. However, studies have shown that women who suffer from severe HG are at increased risk of cognitive, behav ioural and emotional problems during their pregnancy, and McCarthy et al. (2011) also found that these women had a higher rate of spontaneous premature birth, compared with women who did not suffer from HG. There is no doubt however that the thought of the transition from pregnancy to motherhood can be an uncertain time and for some mothers may heighten the risk factors of stress and anxiety (Emmanuel et al. 2009, Annagur 2013).

Other anxiety disorders with similar features include social phobias, post traumatic stress disorder, obsessive compulsive disorder, panic attacks, and eating disorders. Social phobia may have its origins in the teenage years. It is characterised by a marked and persistent fear in social or performance situations, in which there is exposure to unfamiliar people or possible scrutiny by others. For some mothers there may be a fear of humiliation or embarrassment when confronting strangers. The disorder itself can be a problem, but coupled with the thoughts of striving for perfection in motherhood, can lead to self-deprecation and in some cases, panic attacks.

Panic attacks consist of a range of anxiety-type symptoms with sudden onset and a limited duration, often lasting just a few minutes, but to the mother the time span is immeasurable. The cause of an attack is often unknown and may occur when the mother has felt anxious in a similar situation in the past. The symptoms can include palpitations, chest pain, choking sensation, ‘butterflies’ in the stomach, dizziness and feeling detached from reality, caused by hyperventilating. It is often frightening, and the difficulty in controlling the breathing exacerbates the feelings of vulnerability. It can be misinterpreted as an asthma or heart attack. Once identified it is easy to manage by reducing the pace of the breaths.

Symptoms of anxiety are also seen in mothers with obsessive compulsive disorder (OCD) which is characterised by recurrent intrusive thoughts, which can lead to repetitive behaviour. Attempts to resist the urge to carry out these behaviours can lead to severe anxiety (Zimbalidi et al. 2009, Abramowitz et al. 2010). Some of the more common behaviours include frequent hand washing and excessive cleaning. In the pregnant mother it might be obsessive thoughts about her unborn baby and often, in the case of the postnatal mother, it is the constant need to check the baby to ensure they are still breathing. It is believed it begins during the teenage years and can affect one in fifty people. Although not always easy to recognise, for the mother and her family the disruption to everyday life can be quite marked, as the obsessional and compulsive behaviour can prove exhausting.

Post traumatic stress disorder (PTSD) mirrors the symptoms of anxiety and is the collective term for a number of reactions which may happen to anyone who has experienced a severe traumatic or life threatening event. PTSD may be delayed for months or even years and is usually triggered by an incident that is reminiscent of the original distressing situation. This may be repeatedly experienced by flashbacks of the event and nightmares. There have been reports of mothers experiencing PTSD following a difficult labour or traumatic delivery and therefore it is important, as part of the therapeutic process, to encourage the mother to talk about her birthing experience (Garthus-Niegel et al. 2013).

Eating disorders are often caused by, or are a cause of, anxiety. One fifth of mothers suffering from an eating disorder also have a relative who also has the condition, though it is unclear whether it is hereditary, as a result of a dysfunctional relationship, sexual abuse or learned behaviour. It is possible for an eating disorder to co-exist with anxiety or depression.

The condition may be more apparent during the perinatal period as a result of the mother’s personal desire or social pressure to return to and maintain her pre-pregnancy figure following the birth of her infant. It is of concern in both the ante- and postnatal period as both the mother’s and her infant’s nutrition may be compromised. Some women believe their body image is more import ant than the pregnancy, accepting the pregnancy, but not the inevitable weight gain. Some adolescent mothers, in particular, may be fixated with the populist culture that equates a lean body ...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Acknowledgements
• 1 The importance of good perinatal mental health
• 2 The impact of perinatal mental illness
• 3 Assessment and training
• 4 Listening skills and knowledge
• 5 Fathers and perinatal mental health
• 6 Listening to infants
• 7 Cultural experiences
• 8 Resources and looking after yourself
• Index