LIFT – wellbeing after baby

ContactKaren Tate, Assistant Psychologist
Telephone01380 731 335
Emailkarentate@nhs.net
Websitehttps://lift.awp.nhs.uk/
AddressGreen Lane Hospital, Marshall Road, Devizes, Wiltshire, SN10 5DS

About LIFT Psychology
LIFT Psychology is a primary care mental health service for adults (16 and above) in Swindon, Wiltshire and Bath and North East Somerset (BANES). LIFT operates in a stepped care model providing individuals with a quick response to a choice of evidenced based interventions for a wide range of mental health problems, within their GP surgeries and community locations.

A successful feature of the service is the extensive programme of free psycho-educational courses which run frequently across a number of locations on most evenings, many Saturdays and on a number of weekdays. LIFT is an open access opt-in service, which is available to anyone. Patients are not required to be referred to use this service, but instead are given information about LIFT and are then able to choose to make their own appointments or book a place on a course. However we do often receive referrals to the courses from GPs and other professional bodies.

About the Wellbeing after baby course
A recent successful addition to the course programme in Wiltshire is a ‘Wellbeing after Baby’ course which is intended for any parents or carers (male or female) who are experiencing anxiety, depression or general stress since the birth of a baby, regardless of a mental health diagnosis or severity of difficulties. We often see parents with babies, toddlers or young children utilising the service who may attend after the birth of their first child or subsequent children.

The course is delivered by members of the psychology team who provide information about common mental health difficulties and offer evidence based techniques to effectively manage emotional wellbeing. The course specifically looks into aspects of low mood, anxiety, self-esteem, relationships and communication skills; and includes an opportunity to participate in relaxation and mindfulness exercises within the sessions; although there is no obligation to take part.

The Wellbeing after Baby course looks at supporting parents’ needs and encourages attendees to share their thoughts, experiences and invites questions throughout. This can be a helpful process to normalise experiences within the group. However, acknowledging participant feedback, we know that some people may prefer not to verbally participate and choose to just listen. The course aims to help people feel as comfortable and as welcome as possible, so no-one will be asked to do anything they might feel uncomfortable with. There are no “ice-breaker” exercises, and no-one is asked to speak individually. In order to ensure individual needs are being addressed attendees are asked during the first session to anonymously write down any questions, concerns and topics they would like to be covered throughout the course. The course material is then tailored to meet these requests.

The Wellbeing after Baby courses are held at children’s centres which are community venues rather than mental health services. These centres are therefore affirming and accessible environments to all, but their location in deprived areas help to make access easier for local parents.

The starting point
The national statistic is that at least 1 in 10 mothers will be affected by mental illness during their pregnancy and/or in the first year after childbirth; and perinatal mental illnesses are a major public health issue. Estimated prevalence rates for maternal mental health conditions in Wiltshire in 2009-10 were that 547 mothers experience a major depressive illness; 273 mothers experience moderate to severe depression; and 437 would need referral for psychological therapies. This need was not being met by current services and that needed to be addressed; particularly as National Institute for Health and Care Excellence (NICE) guidelines recommend that pregnant women and those with young babies should be a priority for Improving Access to Psychological Therapies (IAPT) services.

A postnatal depression course was previously offered by LIFT Psychology in Swindon and Wiltshire; however, there was a low uptake with few participants attending the course. It became apparent that further development was required to identify and address the barriers to accessing mental health services for parents. In 2012 a collaborative partnership between managers of 4children and LIFT Psychology was established to support the integration of children’s centre services with mental health services, with Wellbeing after Baby courses to be offered by LIFT Psychology in children’s centres across Wiltshire.

The change introduced and how this was done
In recognition of the significant need for improving peri- and post-natal mental health care across Swindon and Wiltshire, several changes were introduced. In 2012 new staffing led to an enhanced interest in implementing such changes. Our initial adaptation was to rename the course ‘Wellbeing after Baby’ as feedback from staff and course attendees suggested that stigma surrounding the term ‘post-natal depression’ could be a potential barrier to access. This is also consistent with the NICE guidelines that state that the term ‘post-natal depression’ is often used inappropriately as a general term for any peri-natal mental disorder. Changing the course name has opened access to psychological support for a wider population of parents and not just those diagnosed with post-natal depression.

A major focus of LIFT Psychology has been to create positive working alliances with local voluntary, community and statutory organisations in order to promote the LIFT Psychology service throughout the county. Working collaboratively with services, in particular children’s centres, we have been able to generate increasing interest in the course and have begun to observe a higher number of attendees. Interest has also been generated through increasing awareness of our service to other perinatal multi-disciplinary team members such as Health Visitors, Midwives, Family Support Workers and Social Services. We attend service meetings, provide printed materials regarding the service and regularly present information to parents at various baby groups.

To ensure that the Wellbeing after Baby course adequately meets individual needs we actively encourage course participants to supply anonymous feedback and suggestions to inform course development. This approach takes into account the context of the individual, and respects that often the difficulties they encounter can be diverse. This has enabled us to tailor the course to meet these needs, for example we have made adaptations to the content of the course to include a session on managing interpersonal relationships. We have also used feedback to address practical difficulties of attending the course such as provision of crèche facilities and offering a varied timetable to account for working parents, school/nursery schedules and baby feeding patterns.

The reformed Wellbeing after Baby course was piloted in September 2012 and was positively received through feedback and successful participant outcomes.

Resources required
The staffing for the Wellbeing after Baby project was initially two dedicated project workers. However, due to the success of the course, and the subsequent need for expansion to meet increased demands; a third project worker became involved. The courses are run by Psychological Wellbeing Practitioners and Assistant Psychology Practitioners who are experienced in delivering Cognitive Behavioural Therapy both individually and in group formats; with a knowledge of peri- and post-natal wellbeing, and overseen by senior managers within LIFT Psychology. All staff within LIFT Psychology are provided with appropriate safeguarding training, and are aware of their responsibilities. Where possible, we have arranged for a qualified Psychosexual Therapist to attend one of the course sessions to talk to the attendees about managing the inevitable relationship changes following the birth of a baby, and effective interpersonal communication techniques.

In addition to our own staff, we utilise the expertise of trained crèche workers, sourced and funded by the children’s centres. This is especially important for reassuring the course attendees that their children are being well looked after during the sessions, allowing them to concentrate their attention on the course material. We also utilise other services by way of signposting; e.g.: Relate, Ask Wiltshire. There is no specific budget for this project alone; the funding comes from LIFT Psychology, through the local Care Commissioning Group.

Every session of the course is accompanied by a hand-out. We also have copies of the Mind booklet: “Understanding post-natal depression” available for parents to take away if they would like additional information on this. Other useful resources which we signpost parents to include:

Impact
At each session, attendees are asked to complete questionnaires from the IAPT minimum data set that screens for depression, anxiety and panic disorders and evaluates the extent that these difficulties may be impacting on the individuals’ day to day lives. The questionnaires are reviewed by facilitators during each session and can highlight where additional support may be required, for example, notifying GPs of any risk issues. Facilitators can privately discuss and signpost individuals to a variety of specialist support services should the individual feel this would be beneficial. The children’s centres also evaluate the effectiveness of the course using a target evaluation form.

For the 7 courses delivered in 2013, there was a 50-80% improvement in IAPT depression and anxiety scores for people who completed or regularly attended the courses. Scores suggest that individuals attending this course often have subclinical threshold depression and anxiety scores on first attendance which can also be seen to reduce throughout subsequent attendances. This may suggest that such psycho-educational courses can act as a preventative measure for clinical depression and anxiety in post-natal parents. This is an area of research that we hope to further investigate.

To ensure we are providing a service which meets individuals need, we encourage all attendees to fill out an anonymous feedback form and make suggestions how the course could be improved. Feedback and suggestions forms are reviewed after the course session and further discussion takes place to fit these suggestions into the course material.

As a service we have found that this course has received positive feedback (highlighted below) enabling people to make changes and gain further understanding to help with their current difficulties:

“The wellbeing course was very interesting.”

“I would recommend the course to someone who was suffering from postnatal depression.”

“What I found most helpful was the information on anxiety and thoughts.”

“The techniques were appropriate and they somehow lodged in my mind enough for me to recall them when I needed them.”

“Being reminded what a tough job being a mum can be.”

“Learning coping techniques; understanding why I may feel the way I do.”

“Very helpful – I’m lucky to get on the course so quickly.”

“I have found it very helpful and hope to do more Lift courses and will also recommend to friends.”

Challenges and how these were overcome
A number of challenges have presented from conception through to implementation of the course. As discussed, our main challenge has been generating awareness of the service and minimising barriers to access in order to gain and maintain sufficient participant numbers. Through continual collaborative working with various services and direct promotion to parents we have begun to observe increased interest and participation in the Wellbeing after Baby course with positive outcomes.

A further challenge that we have encountered concerns course booking procedures. The children’s centres usually operate on a drop in basis for parents; however, LIFT Psychology operates via an online/telephone booking system to opt on to courses. Effective communication and co-ordination between our service and the children’s centres has enabled the relevant information to be efficiently passed between services.

Several challenges have occurred throughout course facilitation such as: conflicts between group members, quiet withdrawn group members, talkative group members, confidentiality concerns, time keeping difficulties and separation anxiety.

We have found that many of these difficulties can be managed through collaboratively generating and agreeing group guidelines with course participants at the beginning of each course, and to refer back to these at the start of each session. Useful guidelines we have utilised include;

  • Addressing confidentiality – especially as parents may know each other from elsewhere.
  • Time-keeping flexibility – participants may come and go as and when they please.
  • Mutual respect towards group members and non-judgemental attitude.
  • Open mind and non-judgemental attitude regarding course material.
  • No putting on the spot – no one will be asked direct questions however acknowledging that individual input can be beneficial for the group.
  • Pause button – a useful tool to resume focus on course material if discussions have deviated away from topic or have become excessively personal.

As concentration and memory difficulties are common symptoms of depression and anxiety, we provide sessional hand-outs to aid recall and cement understanding of topics covered. We also begin with a recap of the previous session before moving on to subsequent topics. This can help alleviate any misunderstandings and presents an opportunity for sharing positive experiences or difficulties utilising the techniques.

How change can be sustained and spread
This has been a joint project between LIFT Psychology and Wiltshire’s children centres in line with best practice guidelines and continuity of care. In its commitment to better practice, LIFT Psychology will continue its membership as part of a key stakeholder group that is involved in reviewing care pathways and mental health provision in Wiltshire for ante-natal care through to when the child is 5 years old.

Following the publication of the NSPCC report “All babies count: Spotlight on Perinatal Mental Health” in June 2013, which highlighted the ‘postcode lottery’ of mental health care provision, a further push has been made to try and close the gaps. With this recent research recommending that the wellbeing of one in ten new-born babies could be improved if their parents had equal access to high quality mental health services, we feel it is crucial to continue to provide psychological support for new parents through Wellbeing after Baby courses. We are constantly looking to evolve the service that we provide in order to best meet the needs of our target group. For example, recent developments of our course manual to include information on effective communication in relationships have come about as a direct result of feedback from parents on previous courses. We continually use feedback in this way to ensure that we are providing the most topically relevant information. The previous attendees have commented about mentioning the course to friends, which will help to spread awareness.

We strive to raise awareness of peri- and post- natal mental wellbeing in the local community, with a particular emphasis on normalising any distress caused by what is arguably one of the most momentous of life-changing events that people can experience. A strong working relationship has been developed with coordinators and other staff at the children’s centres who promote the course to parents. Health Visitors are also informed of courses running in their local area and are encouraged to signpost parents to the course. We are seeking to strengthen our links with other multi-disciplinary team members such as Midwives and local maternity units, Family Support Workers and Social Services. We are hoping to start specifically targeting harder-to-reach, “at risk” groups for peri-natal mental illness, such as young parents or those with pre-existing mental health issues; for example, by improving links with Specialist Midwives/other professionals working in these areas to promote both the course and more generally, the varied services that LIFT Psychology can provide. There has also been some interest from local maternity services about looking into developing a specific ‘Ante-natal Wellbeing’ course, although this is still in its initial stages.

We would welcome the opportunity to disseminate our experiences of working with new parents who have experienced anxiety, depression or stress since having a baby. Our facilitators from LIFT Psychology in Wiltshire have shown their commitment to informing our wider service, as well as other local services, about the positive experience we have had with our courses. In particular, our facilitators have played a central role in the development and implementation of similar courses in our South Wiltshire branch, with a view to further expansion to LIFT BANES. Our staff have supported the facilitation of course sessions and provided advice on course content and presentation.

What has been learned
Peri- and post-natal mental health issues carry an enormous stigma, which can make it hard for new parents to even think of attending one of our courses, for fear of being judged by others. As such, it is important that we normalise the differing experiences that parents have surrounding the birth of their new baby; the choices they make in how to raise their child; and all the associated difficulties that can arise along the way. We attempt to manage this by getting as many ‘points of contact’ in the multi-disciplinary team to signpost to our course, and to relay the same information about it being a supportive, inclusive and non-judgemental environment for new parents to obtain the support that they require. The children’s centres in particular have been a key resource in the success of these courses.

We acknowledge that peri- and post-natal mental health issues can affect the whole family, and we are considering what appropriate adaptations can be made to the course to include support for partners and to address attachment/bonding difficulties with babies.

We have learnt that parenthood evokes strong and differing opinions, and if discussions are not well-managed by facilitators, could lead to conflict and alienation within the group environment. The use of group guidelines can help to prevent these potential ‘elephant traps’.

We are continuously learning and evolving. Every group of parents is different, and by continually listening to their feedback and suggestions, we feel that we can keep improving the service that we offer.