Roles and Contexts in Counselling Psychology

Professionals in Practice

Daisy Best, Helen Nicholas, Mark Bradley, Daisy Best, Helen Nicholas, Mark Bradley

• Publisher: Routledge
• Year: 2022
• eBook ISBN: 9781000574135
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Roles and Contexts in Counselling Psychology looks at the different contexts that counselling psychologists typically work within, offering a snapshot of the 'day job'.

The book provides insights into roles that reflect the human lifespan from birth to death, focusing upon specific mental health experiences and considering roles external to healthcare settings such as expert witness and independent practice. Each chapter is written by a counselling psychologist and offers an overview of their particular specialism and their experiences within it, bringing a unique transparency and personal insight. The book describes the skills that are required for the different roles and their challenges and rewards. It also discusses how the philosophy of counselling psychology is maintained and explores the associated ethical and legal considerations. Further, it takes note of the issues relating to leadership and diversity.

The book is an essential resource for undergraduate psychology and counselling students and trainee clinical or counselling psychologists, as well as qualified practitioners.

Section 1

Lifespan

Chapter 1

Working in perinatal mental health as a counselling psychologist

Claire Arnold-Baker

DOI: 10.4324/9781003159339-2

The importance of maternal mental health during the peri and postnatal period has gained significance in recent years. With this increased awareness has come a recognition of the variety of ways in which pregnancy and the postpartum period is a vulnerable time for women or birthing people. The transition that women go through to become mothers – matresence or ‘mother-becoming’ (Raphael, 1975) – has been likened to adolescence: as women are confronted by changes to their bodies and hormones, social roles, identity, purpose and meaning in life, they can experience an existential crisis (Arnold-Baker, 2020). It is estimated that around one in five pregnant women will experience mental health problems either during pregnancy or within the first year after birth (Royal College of Psychiatrists, 2018). Recognition that motherhood can effect mothers’ emotional experiences during the perinatal period is not a new concept, with Eastman coining the term ‘baby blues’ in 1940 to cover a myriad of emotional experiences. However, until recently mothers often felt there was a binary choice, having to describe their emotional experience of motherhood as either postnatal depression (PND) or ‘baby blues’ – a view that persisted despite literature such as Price’s (1988) book Motherhood: What It Does to Your Mind that highlighted the emotional and psychological changes that can occur postpartum. Yet the reality of a woman’s or birthing person’s experience is far more complex than the restricted realm of depressive disorders and can result in issues around matresence, anxiety, eating disorders, obsessive compulsive disorder (OCD), phobias such as general health anxiety or tokophobia (fear of giving birth), birth trauma and post-traumatic stress disorder (PTSD), and psychosis. This chapter therefore aims to highlight the complexity of the perinatal period and considers the varied and important role counselling psychologists play in working with this diverse client group.

The intricacy of the perinatal period in terms of mental health is an area where counselling psychologists have much to offer. In fact, as greater awareness has been generated through campaigns or research – for example, by the Confidential Enquiry into Maternal and Child Health (CEMACH, 2007) – it has highlighted how perinatal mental health has become a significant concern in terms of both economic costs and the cost to mothers’ lives. It has been estimated that the impact of maternal mental health costs the UK approximately £8.1 billion per year (Bauer et al., 2014), which does not include the cost to people’s lives. This compelling evidence has shifted policy within the NHS towards offering more support in the perinatal period, a much needed and important development.

Perinatal care is now part of the NHS Long-Term Plan, which aims to transform physical and mental health care provision. The plan gives a commitment to extend the period of time in which specialist help can be offered from one (the extent of the current provision) to two years postpartum, in recognition of the fact that mothers often delay seeking help or need more extensive help depending on the severity of their mental health problems. The Long-Term Plan is ambitious in its aim to offer help to 24,000 new mothers by 2023/4, which is in addition to the 30,000 women the NHS currently plans to help in the year 2020/21 (Psychological Professions Network, 2019). In order to meet these targets, new specialist perinatal psychology positions have been created within the NHS.

Psychologists working in the NHS will either be attached to a perinatal mental health team in a trust, or they may work in a mother and baby unit (MBU). The perinatal mental health team will normally work with moderate to severe mental health issues, which account for 5 in 100 women. These services are usually only accessed through referral and do not accept self-referrals from mothers or birthing people. The perinatal mental health team will often work closely with maternity services as well as with local community and in-patient mental health services, primary care services, social services and other third-sector organisations.

However, around 2–4 mothers per 1,000 will need more specialist in-patient care and will be referred on to a MBU (Royal College of Psychiatrists, 2018). These are important units as they keep the mother and baby together while giving the mother multidisciplinary support. The multidisciplinary team at a MBU will include psychiatrists, mental health nurses, nursery nurses, social workers, psychologists, health visitors, nursing assistants and administrators. However, this provision is limited, with only 19 MBUs in England, two in Scotland, one in Wales and none in Northern Ireland currently (Maternal Mental Health Alliance, 2019). This means that women may be unable to secure a place in a unit or they may be placed in a unit some distance from where they live.

The NHS is not the only setting where in which counselling psychologists can work within perinatal care; there are also opportunities to support mothers and birthing people in third-sector organisations. However, it is most likely that counselling psychologists will specialise in this area in their private practice. Working independently enables counselling psychologists to accept self-referrals and to work with mothers and birthing people past the first year, which is important as some mental health issues emerge later or it takes time for the individual to overcome any blocks which might have prevented them from seeking help sooner. Counselling psychologists work with a range of issues in private practice and are not restricted in the scope of this work by the severity of the presenting issue.

Day-to-day skills, roles and responsibilities

The main work of a perinatal counselling psychologist is to provide psychological therapy to clients who are suffering from mental health issues and distress during pregnancy and the first year postpartum, and beyond if working privately. Counselling psychologists will conduct assessment sessions and formulate treatment plans, often liaising with other members of a team. It is important that the perinatal counselling psychologist has a range of knowledge and understanding of not only mental health but also physical health care, particularly in maternity. Having a comprehension of the physical process and co-morbid health conditions related to the perinatal period will enable counselling psychologists to properly appreciate the struggles that women and birthing people go through during this time. It is a specialised area, and one where the counselling psychologist must be able to integrate and have an in-depth knowledge of not only maternal mental health but also infant mental health and developmental psychology, as matters pertaining to these areas often arise within the therapeutic work. Equally important is an understanding of family dynamics and how relationships with the partner and extended family may change during the perinatal period. Knowledge of these different disciplines makes this an interesting and rewarding area of work.

Working in private practice enables a greater scope of work. Most clients will self-refer, and many women and birthing people prefer the anonymous and confidential aspects of being supported by a therapist who is not connected to maternity or health visiting services, fearing what seeking help may communicate to health care professionals. There is still huge stigma for mothers around seeking help, and many mothers equate the need for additional support with having failed or not being a ‘good’ mother. For some there is also a fear that if they admit to not being able to cope their babies will be taken from them. It is therefore important that counselling psychologists are able to normalise experiences within the perinatal period to enable women to gain the help that they need.

Being a new and expanding field of counselling psychology there will be opportunities for counselling psychologists to play a role in service development; in addition to offering training, education and supervision to those working in maternal mental health that is informed by both practice-led and research-based knowledge. Furthermore, counselling psychologists can make a major contribution to understanding this complex area of mental health through their own research – indeed, there has been a rise in doctoral research from a variety of perspectives being produced by trainee counselling psychologists in recent years (Arnold-Baker, 2020; Smallwood, 2017).

For those counselling psychologists who are interested in social justice and policy development, there are a number of ways to be involved. Organisations such as the Maternal Mental Health Alliance campaign and lobby for better experiences for women and birthing people. The Division of Clinical Psychology’s faculty of perinatal psychology is also involved in policy development, and counselling psychologists are eligible to join and take part in discussions, although we do not currently have voting rights.

Working relationally in the perinatal period

Pregnancy and the postpartum period are complex times, and they create a bio-psycho-social-spiritual phenomenon (Garland, 2020) for women and birthing people. It involves an intricate web of interconnecting dimensions which need to be understood, including their impact on the mother’s or birthing person’s experiences. It is worth considering an existential framework when conducting assessment sessions and devising formulations to take into account these different dimensions. While an understanding of each client’s presenting issue is needed, their context and history are also important in understanding the impact they have on the mother. This will include an exploration of any previous mental health challenges or trauma, their physical experiences and symptoms, their social connections and support systems, how pregnancy and motherhood has affected their sense of self and how this has impacted on their values and beliefs. Table 1.1 highlights areas to explore within the therapeutic work.

The use of an existential framework to explore a mother’s or birthing person’s world ensures that a holistic view is created and there is proper recognition of how the different dimensions interact with each other. For example, expectations and values in the spiritual dimension connect with judgements of others in the social dimension, which then impacts the mothers’ sense of self in the personal dimension.

As the perinatal period is a time of vulnerability for women and birthing people it is important to create a containing and holding therapeutic relationship. This requires the therapeutic relationship to be more positive and validating than other therapeutic relationships (Stern, 2004). Equally important is an understanding of the ‘good enough mother’ concept (Winnicott, 1989) and how it connects to attachment parenting, and also how the mother’s initial sensitive responses to her baby lessen over time, which enables the infant to experience frustration and learn how to tolerate and cope with these moments. This is useful when counteracting the myth in Western cultures that women must be perfect mothers, which causes intense pressure to make the right choices at the right time without necessarily having the knowledge or experience to do this successfully. This in turn leads to feelings of stress, anxiety, guilt or depression. Challenging expectations around ‘normal’ or ‘natural births’, the ability to breast or chest feed and being a ‘good mother’ will help women and birthing people to normalise their experiences.

Table 1.1

Dimension	Questions to consider during assessment
Physical	How do you experience your body – pregnancy, birth and breastfeeding? feel about your sexuality and your sexual body? experience time and temporality? manage lack of sleep and exhaustion? experience the paradox of life and death, or health and illness? experience any trauma or previous trauma that has been retriggered?
Social	How do yo...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• List of contributors
• Introduction
• SECTION 1: Lifespan
• SECTION 2: Condition specific
• SECTION 3: Beyond healthcare
• Index