Working with parents and their infants lends itself to a systemic perspective, and in this role I am able to offer a more comprehensive service to families than is generally available in primary care, a bit of an enigma. For the purpose of this article I will generally be discussing my work with mothers and young babies, a high number of the referrals I receive have identified women with post-natal depression as the presenting problem. However as a systemic therapist it is not possible to view the 'client' in isolation, one client leads to another, as the well being and mental health of the child cannot be ignored, in addition there is often a partner to consider, extended members of both families, work contexts and so it goes on. Women present months even years after giving birth with depressive symptoms and often these initially developed soon after having the baby but have been left unacknowledged until a point of crisis. There are also those who have survived abuse as children, poor relationships with parents (mothers in particular) or have had previous episodes of depression associated with trauma or loss. Indeed I have seen fathers who develop depressive symptoms soon after the birth so it should be kept in mind that there is no 'typical' case.
From the family life cycle perspective, (Carter & McGoldrick 1989) becoming a couple and having a child is a significant time of transition. It is widely portrayed through advertising as a time of blossoming and happiness, any Mothercare catalogue will show a smiling pregnant woman aglow with anticipation, or an equally happy new mother with a smiling baby and an implied air of contentment. Clinical observation and personal experience make me very cynical of these representations and concerned about the impact it has on clients.
I regularly go into new parent groups with the remit of talking about maternal moods and feelings and I have learnt so much from the mothers there, I start my session by asking them to introduce themselves and their baby and say one thing that has surprised them about being a mum. This often gives rise to an immensely rich session, led by the group on aspects of their experience of becoming a parent, some of which I am going to share in this article.
Women today are fortunate to be able to choose their desired place of delivery, they are encouraged to make a birth plan, they are taught about natural labour but increasingly ante-natal parentcraft classes stop at the delivery room. A birth experience that is traumatic or unexpected can have a profound effect and is usually not anticipated despite the classes.There is limited opportunity to explore the impact of a new family member, or warning of the natural moods and feelings of motherhood.
Many of the women I work with who are presenting with anxiety and depression tell me over again how they feel they have lost themselves …Sheila becomes known as little Rory's mum. and for many the actual monotony of caring for a new baby, with the loss of a sense of structure in their everyday life, career women who are used to the cut and thrust of their working environment find themselves unable to control their waking day (or night for that matter). The feedback of peers and work colleagues that boosts stressed self esteem is missing, the clearing of a desk at the end of the day and "me time" is absent, instead there is no end of the day, this has become a 24hr day, an endless round of nappies, feeding and rushed meals, with snatched periods of sleep.
The influences of the family and societal myths surrounding motherhood make great demands on some, with unrealistic expectations of themselves, conflict between their family of origin and their current lifestyle choices. (Vetere & Dallos 2003). One example frequently cited is the evolving relationship with an over intrusive mother in law or mother, (perceived and real) as well as the constant stream of unsolicited advice and gentle (or not) criticisms. As professionals I sometimes feel we too over burden new parents with advice and instruction, with the objective of allowing informed choice and evidence-based practice. All this can serve to disempower a vulnerable parent who becomes so overwhelmed by advice and opinion she is unable to focus on what her baby is telling her. One of my personal frustrations is the wealth of books and magazines that become so addictive to information hungry parents desperate to get it right. The primary failing of these is that the baby has not read any of this so he/she just relies on basic instinct which the poor parent cannot interpret because it is not exactly like the book! I confess… I have on occasion confiscated the book and worked on the baby teaching the parent to good effect.
The relationship between mother and child, or 'bonding' is too often portrayed as instantaneous love at first sight with no recognition that attachment, of which bonding is a part, is a longitudinal process taking weeks or months deepening as the baby develops. It can be overlooked that the father too experiences the process with his child, but it may differ to that of the mother. Personally, I feel that first smile from a baby is designed at just the right moment, when an overtired parent, who feels overwhelmed by the unremitting demands of parenthood is suddenly acknowledged. Witnessing those first smiles and the reciprocity they evoke is one of the perks of the job. It can all suddenly seem less daunting.
If this article is starting to leave you feeling a bit hopeless then that's good, because now you can appreciate just how many of my clients feel. Remember my work is primarily with parents who are depressed or emotionally vulnerable. Conversations acknowledging feelings like this bring relief to many as they realise they are not failing, normalising in peer groups gives them a sense of belonging and above all I try to impart an optimism that actually they are not 'the only one', and that admitting life is tough is not going to bring Social Care on the doorstep to whisk your baby away (a common fear).
Using Infant Massage, Attachment and Reciprocity
Working with mothers with depression and anxiety after having a baby requires sensitivity to the needs of both as well as the partner. One intervention that has proved successful since it was introduced is the use of infant massage. Having trained as a certified infant massage instructor with the IAIM (International Association of Infant Massage), I found a training that complemented systemic practice. The programme focuses on fostering communication through nurturing touch, embracing theories of attachment, whilst acknowledging the need to be mindful of the new mother's self esteem. Research into using infant massage with depressed mothers, demonstrate outcomes that are very positive. (Onozawa et al 2001, O'Higgins et al 2008)
I offer infant massage in specialist referral groups, of up to 8 mother's with depression or other mental health issues and their babies. The group comprises of 5 sessions of massage followed by a discussion. Initially we only were able to offer it as a secondary service but following an award and a much stated vision that it should be available as a primary intervention, this year sees it available through all health centres and children's centres within the PCT. Much work is going into ensuring it remains delivered in its purest form emphasising the reciprocity, attachment process and promoting the mother's self esteem.
The delivery of the massage also involves seeking permission to massage, respecting the baby's desire to be touched or not. It is only conducted with the baby fully engaged in a quiet alert state and is only done by the mother. If a baby is asleep or crying massage is not done. We use life size dolls to demonstrate and if baby is not wanting massage or is sleeping then parents are encouraged to participate using a doll. This is the opportunity for mothers who are anxious and over intrusive, who may have fussy babies, who have babies who have been in Special Care and subject to invasive procedures, all to learn how to communicate sensitively through touch. Attention is drawn to disengagement cues and when massage needs to be stopped. I like to think it introduces the idea of a teaching for life that a child can withdraw permission from unsolicited touch. It is not just a session learning how to do nice strokes on your baby!
The groups address relationship issues, issues of self-identity, and are given knowledge about nurturing positive mental health through diet and exercise, demonstrated by a snack of fruit after massage during the discussion, (though often sabotaged by the contribution of chocolate biscuits from the group participants as they become more confident during the course). The discussions allow some normalisation of the process of entering motherhood, for some whose first baby it is, the difference between the initial feelings of exhaustion of motherhood and the start of a depression is hard to discriminate. The discussions are shaped by the participants and what they feel comfortable to share.
Recognising their feelings in others, exploring alternative perspectives with peers and devising new strategies for management often is the most helpful intervention. In addition they embrace a deeper relationship with their baby and the privilege of watching a mum, who lacks confidence with her baby in the first group, then seeing their relationship blossom where the reciprocity develops so that by the last group they are cocooned in their own world, full of smiles and chuckles, cannot adequately be put into words. The feedback from the groups is always positive, the outcomes are immense. Many of the groups become self-supporting, meeting up for many months after and emboldened by their new sense of belonging tackle the daunting task of accessing toddler groups and other parent child activities.
Work with the parental couple
One aspect of my work is the opportunity to work with the couple as a dyad, which is well documented in having positive outcomes when there is one partner with depression. (Leff et al. 2000) (Jones and Asen 2002)
The gender role expectations of becoming a father can be just as overwhelming as those of becoming a mother. There is limited acknowledgement of the impact of new fatherhood, with much professional attention (and services) being focussed on the mother infant relationship (Vetere & Dallos 2003). They are encouraged to participate in maternity care, but the weeks and months afterwards when the excitement has passed is a time when couples can find themselves struggling to find time for themselves, their intimacy may be more limited, power issues may arise with one going out to work and being the wage earner and the other working equally hard but unwaged at home and the whole dynamics of the relationship change exacerbated by the presence of depression.
Sometimes in work with both parents much time is spent exploring his experience and expectations. there is the need to support and educate about the impact and process of the depression, working with both as to how he may support her, but also acknowledging his distress and uncertainty. It is important to explore the experience of the birth, and the feelings about caring for such a vulnerable and dependent baby. These sessions can be very rich with both parents learning about each other and forms the 'secure base' they need to feeling fulfilled and competent as parents. The influences of other generations can change dramatically when a new baby comes along, deskilling the new mother, privileging the relationship between mother and son, or mother and daughter, causing conflict between the new parents. Again the work here is about strengthening the new parental hierarchy, whilst identifying constraints and constructing strategies to reconcile these.
Co-creating alternative stories
The work I do with families is from a systemic perspective, incorporating different models but primarily I strive to adopt a narrative stance. (White & Epston 1990). For many women the process of re-authoring their story helps with the adjustment of becoming a new mother. For some it is the rewriting old family scripts (Byng-Hall 1995); often of abuse to facilitate recovery with a new script of competence and safety.
Some tell me stories of perceived failure, as a child who was abused, or a rebellious teenager where drugs and antisocial behaviour helped mask their distress, with self harming the coping strategy and where the conversations of non achievement and potential risk are the dominant discourses. When dealing with frank safeguarding issues I take a more structural perspective, needing to adopt an expert position and define limits and expectations. I am fortunate in that with identified safeguarding issues where there is multi-agency involvement, I am able to retain a therapeutic stance whilst working in collaboration with statutory services. In all these complex cases I find working transparently has the best outcomes, and my reflections following a recent attendance at the workshop at IFT with Jaacko Seikkula reinforced for me the efficacy of this approach. Significantly, although referring greatly to his work with clients with psychosis and their families, the description of the horizontal and vertical voices in an open dialogue session allowed me to construct a position whereby I keep the infant /child's voice in the room, as well as in mind. (Seikkula 2009)
Some of my clients having suffered abuse emotional, physical and sexual in isolation or combination when younger, struggle to cope with the scars and the shame and anger they feel. Having their own child brings a resurgence of these memories amidst a confusion of feelings. The fierce protection they feel for their own babies brings the question why they were not protected. Commonly their fear is that as the abused they may be viewed as an abuser, or a 'poor' parent. This overwhelming fear often gives rise to intense anxiety, compounded by the new situation of motherhood. Sometimes the act of childbirth reignites the memories, reliving the trauma, and for some this gives rise to the symptoms of PTSD. For these women it is important to combine an acknowledgement of their position as a new parent with their needs as survivors and not to assume to exclusively pathologise their response. Many of my clients have no history of frank abuse, but may have relational issues with other family members or parents, are trying write their own family scripts and are facing opposition from other generations.
The story of Lisa describes a process I find particularly helpful, where the history involved sexual abuse, followed by teenage years of drug misuse and antisocial behaviour, and anger management issues. Sitting down with Lisa one day, we acknowledge the past, we are clear about what is not an acceptable risk to the baby, but we spend time talking about what Lisa had achieved, how she was responding to her new baby, what her strengths were, her resilience at surviving her teenage years and now being drug free.
Lisa was used to repeated conversations about what she had done wrong, what she may do wrong, to risk assessments, to actually being rejected by services because of her attitude but she was surprised to have time to look towards the future, to an acknowledgement that she was trying to do things differently. This will be framed as her new story which she now has the opportunity to re-author. The ideas excite her, her whole demeanour changes as she recounts what she enjoys and how in her role as a mother she can make choices and influence the future. Most of all her new story involves being respected by someone and having an opportunity for a difference.
Working in the clients home
The majority of my clients choose to be seen in their own home. This is often for practical reasons reflecting difficulties in childcare arrangements. For some it is their only opportunity to have any sort of therapeutic work, as referrals to other services require attendance at groups (no crèche provided so childcare issues) or appointments at non-child friendly offices. A lively infant or toddler is less of a liability in familiar surroundings, with access to his cot for a daytime nap or where he can be distracted or engaged easily, reducing the stress on the client. This is truly working in context and is a huge privilege for me. It gives opportunity to observe parent /child interaction, and the environment in which life is lived.
The responsibility of seeing a mother and working in therapy with her, then leaving her with a small child or baby to care for is huge. One has to be mindful of the emotional aftermath of a difficult session. It could be argued that those interventions should not be held at home, but experience has demonstrated to me that with adequate time spent returning to the present, planning how to manage the rest of the day and focussing on the clients resilience and competencies maintains a safe therapeutic space. I also hypothesise that it gives a sense of security to a vulnerable woman to be in her own space.
When it comes to ending the work there is always space for some mental health promotion, reinforcement of competencies and understanding and recognising triggers. The client has the opportunity to self refer should her mood deteriorate or the situation change. Relationships with clients where there may be a child with a disability or in one case an infant death that needs working through with a subsequent pregnancy may last many months but always with a focus on competency and resilience. Even re-referral is re-framed positively reinforcing the client's autonomy and expertise with their own mental health. Re-referrals seldom are as lengthy as initial episodes of therapy, sometimes with only one or two sessions needed. Fears regarding subsequent pregnancies are framed as an opportunity to reuse skills previously learnt in managing mood and worked with as another chapter in an ongoing narrative.
And finally….
I am not an expert, all the parents and babies I have worked with have taught me and shared their expertise, I just have the skills to facilitate the transitions in evolving family life. A friend whom I trained with read this article and one of her comments really moved me…
" I read it on my way to a session with a mum with long term depression / personality disorder 'issues'- the article focussed me on thinking about experiences of mother/infant bonding and my client and I had a very powerful session as she spoke about her experiences of becoming a mum- she'd never done this before and her daughter is seven – so thank you."
This was later identified as a significant moment in the therapy.
I hope it can be of some use to you too.
The cost of a one hour session with Carolyn is £57.50
References
Byng-Hall J. (1995). Rewriting Family Scripts, Improvisation and Change. New York: Guildford
Carter, E. & McGoldrick M. (1989) The Changing Family Life Cycle 2nd Ed Boston MA Allyn & Bacon.
Jones E & Asen E (2002) Systemic Couple Therapy and Depression London: Karnac
Leff J.,Vearnals S. Brewin C. R. Wolff G. Alexander B. Asen E. Dayson D. Jones E. Chisholm D. &Everitt B.(2000) The London Depression Trial. Randomised Controlled Trial of Antidepressants v. Couple therapy in the Treatment and Maintenabnce of People with Depresssion Livng with a Partner: Clinical Outcome and Costs. British Journal of Psychiatry 177: 95-100.
O'Higgins M, St James Roberts I, Glover V. (2008) Postnatal depression and mother and infant outcomes after infant massage. Journal of Affective Disorders 109(1-2): 189-92.
Onozawa, K., Glover, V., Adams, D., Modi, N., & Kumar, R. (2001). Infant massage improves mother-infant interaction for mothers with postnatal depression. Journal of Affective Disorders, 63:201-207.
Seikkula Jaacko 2009 Open Dialogue in Severe Crises with Families and Professionals. Workshop Monday 12th & Tuedsay 13th October 2009 Institute of Family Therapy
Vetere A & Dallos R (2003) Working Systemically with Families formulation, Intervention and Evaluation. London:Karnac
White M and Epston D (1990). Narrative Means to Therapeutic Ends New York, Norton
My thanks to Caroline Pipe MSc for her support in the writing of this article and of course all the mums, dads and babies who have taught me so much.
