We have developed a 12 week Dialectical behaviour therapy informed program for mothers with mental health problems to learn about emotions and ways of coping with them effectively. The skills taught in the group are specific to the experiences of becoming a mother and include teaching on mindfulness, emotional regulation, distress tolerance and people skills. We have run 4 groups now (including an initial pilot group) and evaluated the impact.
Co-Production
From start: No
During process: Yes
In evaluation: No
Evaluation
Peer: Yes
Academic: No
PP Collaborative: Yes
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Dr Hannah Wilson - Consultant Clinical Psychologist Southern Health NHS Foundation Trust
We have developed a 12 week Dialectical behaviour therapy informed program for mothers with mental health problems to learn about emotions and ways of coping with them effectively. The skills taught in the group are specific to the experiences of becoming a mother and include teaching on mindfulness, emotional regulation, distress tolerance and people skills. We have run 4 groups now (including an initial pilot group) and evaluated the impact. The outcomes suggest the group content was well received by the service users and helped improve wellbeing. Staff were trained in delivery of the skills classes and regular supervision to support staff development was integral to the service development.
The perinatal time is full of important life changes and transitions: taking on new roles and responsibilities at the same time as losing some; new relationships are formed as well as lost as contact with friends whose lives are taking them in other directions end. It can be emotionally charged even when things are going smoothly. It can be a time when previous losses are revisited and old wounds resurface. Even if we have learnt effective strategies for coping before becoming a parent, the set of challenges faced with a new born infant means it can be difficult to know how to apply and generalise these skills to how life is now.
Having a child and childbirth can dysregulate evenly the most emotionally robust. It can highlight for the first the difficulties of women who have not had the opportunity to acquire emotion regulation skills. Harnessing this enhanced awareness and motivation for change is one reason to target women presenting for help during the perinatal period. It is also likely to have a positive impact on the infant’s mental, emotional, cognitive and behavioural long-term development as the impact of maternal wellbeing and mental health on these developmental factors is well known (Pawlby, et al, 2009; Pickles, et al. 2013; O’Donnell et al,. 2014).
The skills taught in the program were drawn from DBT (Linehan, 1993). DBT is a cognitive behaviour therapy developed for people with Borderline Personality Disorder. It has been shown to be effective at reducing suicide rates, hospital admissions, self-harm and impulsive behaviours associated with this condition (Linehan, Armstrong, Suarez, Allmon and Heard, 1991). DBT-informed treatments have been delivered in a multiple settings, adapted for various diagnoses (e.g. Clarke and Wilson, 2008; Durrant, Clarke, Tolland and Wilson, 2007; Sambrook, Abba and Chadwick, 2006; Davidson and Tyner, 1996), and recommended by NICE (2007).The skills group was supported with a weekly consultation group for the key-staff working with those women. This was based on the DBT consult group offering supervision, education and support. The consult group encouraged the sharing of multi-perspectives and the use of dialectics.
The skills taught were from Linehan (2015, a and b) and adapted to specific issues relating to this client group. Mindfulness skills taught focused on acceptance of parenting and intersubjectivity (mind mindedness of baby {i.e. being aware of our thoughts about baby’s thoughts}, non-judgement of emotional reaction to crying, etc.) and incorporating this skill into everyday activities (e.g. feeding and bathing baby). Distress tolerance was taught with specific examples of radical acceptance of the loss of roles and previous freedoms when becoming a parent as well as how to soothe ones’ self in order to soothe baby when distressed. Infant development education was also included to look at the role of the parent to hold/contain distress for the infant while they develop these skills of self soothe. Emotional regulation skills focused on supporting women to understand emotions and their function so to know when to problem solve and when to act opposite using frequent examples of parenting paradigms (e.g. baby needs feeding in the middle of the night and you feel frustrated). Guilt was often discussed as thoughts of “not being a good enough parent” arose along with the high demands and expectations of modern life. Handling this guilt and bringing compassion to the parenting role was highlighted as well as past experiences of being parented. The specific skill of forgiveness for both self and others was taught. Interpersonal effectiveness skills were adapted to explore making new friends when going to baby groups, how to handle the expectations and offers of help (or lack of them) from others as well as ending relationships when necessary.
All the mums attending the group have been asked for feedback about the impact. One mum stated ” The group has provided a solid foundation of skills for life which are useful and practical for dealing with day to day life. It was an absolutely amazing course with very helpful leaders. I have learnt so much and have been helped a great deal. Thank you so very much”.
Wider Active Support
We collaborated with local peer support groups, Hampshire Lanterns and the local trust CAST service user group, to develop the program. The referrals of women to the service are taken from midwives, health visitors, GPs and other local mental health teams. We also involved a local crèche service to help increase access to the group for mothers with young children.
Co-Production
We have included past members of the group into the skills class. A past member is invited to talk to the group about their experiences and what helped them learn the skills and continue to use them in their daily lives. We have found this is very well received and really helps motivation and commitment.
Looking Back/Challenges Faced
Having a crèche and support for child care has been crucial and ensuing this is available has been a learning point. Making the group as accessible and friendly as possible has also proved to be essential as getting our with a young child is hard enough let alone when you are also struggling with anxiety and/or depression.
We have also recognised the importance of including dads and are working on how best to do this. We also want to measure the impact on the mother infant relationship so also want to explore how best to capture this change.
Sustainability
Rolling training package is in place for new staff members joining the team to ensure the skills are not lost and the group is continually supported. Funding has also been sought from Wessex Strategic Health Authority to develop the training package further.
Evaluation (Peer or Academic)
The program was evaluated using core outcomes measures. An academic paper has been written and submitted to the Behavioural and Cognitive Psychotherapy journal in April 2017. This paper was collated by Dr Hannah Wilson, Consultant Clinical Psychologist and Ms. Alexandra Donachie, assistant psychologist.
Outcomes
The outcome results for the group program are summarised below:
Demographic characteristics
Table 1 describes the demographic characteristics of the 32 perinatal community cohort (3 pregnant and 29 postpartum) who were initially referred to the group. Women averaged 31 years of age (sd = 5.89) and all were white British (100%). There was a relative balance between women who were married (40.6%) and those cohabiting (46.9%), whilst fewer women were single (9.4%), and divorced/separated (3.1%). In regard to parity, 37.5% of women were first time mothers, 50.0% of women had between 2-4 children, and a minority (9.4%) had 5 or more children.
– [Insert Table 1.] –
Primary psychiatric diagnosis and comorbidity
The most common psychiatric diagnosis was complex post-traumatic stress disorder (37.5%; n = 12), 6 women had bipolar depression (18.8%), 5 women had unipolar depression (non-psychosis; 15.6%). 25% of women presented with comorbid diagnosis; in which post-natal depression and anxiety (PND) was the most represented (12.5%), followed by PND and an eating disorder (6.3%), and PND and c-PTSD and bipolar and c-PTSD (both: 3.1%) respectively.
– [Insert Table 2.] –
Symptomatic change
Fig 1. depicts significant reductions in overall psychological distress (CORE-34) at the end of the ECS group compared with the start (time 2 v. time 3: t = 5.32, p< .001, r = .83). For three of the four subscales there was a significant improvement in wellbeing (m = 3.57, sd = 2.65), problems/symptoms (m = 9.64, sd = 7.62), and functioning (m = 9.29, sd = 6.74). The risk subscale was non-significant (t = 1.14, p> .05). There was a significant improvement in mental health confidence and self-efficacy (MHCS: t = -8.03, p< .001, r = .91), including all three subscales, optimism (m = -6.86, sd = 3.35), coping (m = -7.64, sd = 4.20) and advocacy (m = -2.14, sd = 2.25). There was a significant improvement in managing emotions more effectively (LES: t = -9.42, p< .001, r = .93). There was no significant change reported for the wait list control period (time 1 v. time 2: CORE-34, MHCS, LES; all p> .05).
Insert Fig.1.here
Satisfaction Questionnaires
Thirteen of the 14 women completing the group filled in a satisfaction questionnaire at the end of the group. The mean total score of the Likert scaled questions was 23.57 (sd =1.63) (n = 13, possible range 0 – 25). Reponses to the open questions suggest that 100% of those completing the questionnaire felt they had achieved their goals for attending the group. The emotion regulation skills were named by 9 of the 13 (69%) women as the most helpful skills (e.g. being able to sit with emotion, name and describe an emotion and act opposite when an emotion is too high). Being able to be in a group, knowing you are not alone and sharing stories was the best thing about the group for 7 of the 13 (59%) women.
Sharing
The results have been shared at several conferences including the Royal College of Psychiatry Perinatal Network conference in London, the Dialectical Behavioural Society conference in Manchester and the British Psychological Society Perinatal Faculty annual conference. The work is also being shared through peer review publications.
Is there any other information you would like to add?
The Southern Health NHS Foundation Trust Perinatal Team are a very dedicated and committed team of professionals who go over and above the call of duty on a regular basis. They are passionate about the work they do to support families with mental health problems make positive changes to their lives. They demonstrate compassion and care for all women referred to the service. By developing this project the team have offered an innovative group program that is one of a kind. The staff training and leadership has ensured the sustainability of the project. The support of the training and opportunity to offer an innovative group has also improved staff morale. By increasing the wellbeing of women in the care of the team, the group also improves patient safety,
