Caroline Brunt and Bindi Gauntlett describe how midwives are using the human givens approach to help support women during pregnancy and after birth.
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Pregnancy and new motherhood, while commonly a time of excitement and joy, are often a source of anxiety and stress for many women.
While midwives are routinely taught to deal with both normal and out-of-the-ordinary pregnancies and births and the principles of healthy living, they are not taught how to deal with the emotional and psychological factors that may put women’s health at risk during pregnancy and after. They are not taught how to deal with addictions, aggression, emotional distance, anxiety and fear. So, while feeling enormous compassion for women in difficult circumstances, midwives commonly feel quite ill equipped to help them. In Salisbury, however, we are now routinely introducing midwives to the human givens approach. It offers a practical means of giving midwives the confidence, and greater knowledge and skills, to offer appropriate help to women with mental health problems, whether mild, moderate or severe.
For, while deaths, thankfully, are relatively rare (although suicide has repeatedly been highlighted as a leading cause of them) Martin Fletcher, Chief Executive of the National Patient Safety Agency, which funds three-yearly confidential enquiries into maternal deaths, commented after the latest report,
1 that
“we must redouble our efforts to provide safer, better health care for vulnerable women during and after pregnancy”. Midwives are seeing more and more women who are in poor physical and mental health during and after pregnancy because of compromised life circumstances. Every area of Britain has its own challenges and our own area, Wiltshire, Hampshire and Dorset, is certainly no different, having significant pockets of deprivation.
The publication in 2007 of antenatal and postnatal mental health guidelines by the National Institute for Health and Clinical Excellence (NICE) prompted the introduction of human givens training for our midwives. For some time, there has been an understanding of the need to screen women for serious mental health disorders and healthcare professionals have asked questions about past or present severe mental illness, including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression. If the healthcare professional or the woman herself has significant concerns, her GP has sought further assessment and possible referral to specialist mental health services.
However, the NICE guidance goes further, recommending specifically that all women at their first contact with antenatal and postnatal services should be asked two questions to identify possible depression. These are “During the past month, have you often been bothered by feeling down, depressed or hopeless?” and “During the past month, have you often been bothered by having little interest or pleasure in doing things?” If the woman answers ‘yes’ to either of these, a third question should be con- sidered: “Is this something you feel you need or want help with?” Caroline, as head of maternity services, was aware, from her conversations with midwives, that, if they got a ‘yes’ to the question about wanting help, they would rapidly feel out of their depth, and she wanted to be able to address this, using human givens principles.
Strategies to help
NICE advises that, for mild or moderate
depression, the following should be considered: “self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise); non-directive counselling delivered at home (listening visits); brief cognitive behavioural therapy and interpersonal psychotherapy”. NICE also puts emphasis on the prevention of mental ill health. For pregnant women who have suffered depression or
anxiety previously and who currently “have symptoms of depression and/or anxiety that do not meet diagnostic criteria but significantly interfere with personal and social functioning”
2, it recommends that individual brief psychological treatment (four to six sessions) such as inter-personal psychotherapy or cognitive behavioural therapy should be considered; for those who have not suffered previously, regular, informal social support, individual or group based, can be offered during pregnancy and the postnatal period.
The recommendations for intervention, for both mild and moderate depression, subclinical depression and anxiety, clearly allow the incorporation of human givens techniques. Applying human givens principles can certainly qualify as “guided self-help” and informal social support, and therapy based on the human givens approach is certainly an individual brief psychological treatment. So Caroline, herself a human givens counsellor, arranged training for all the community teams. Forty members of staff, spread across six teams, who carry out the risk assessments early in pregnancy, have attended in-house workshops on the human givens approach to dealing with depression, anxiety and understanding addictions. Although NICE urges that pregnant women who need psychological help should receive it within one to three months of initial assessment, pressure on services means that this doesn’t always happen. Therefore, the training aim is to equip midwives with sufficient basic tools, so that they have the confidence to decide whether they themselves can give vulnerable women the support required.
Senior midwives who support women who experience birth as traumatic or present with psychological distress have also undergone the training and, in addition, have learned how to carry out the rewind technique, so that they can offer women simple detraumatisation, if and when appropriate. (See
Reducing Fears of Birth, at the end of this post)
Bindi, a former nurse and health visitor as well as a human givens counsellor who works from the Wiltshire Human Givens Centre, tops all this up by visiting our six community teams at intervals to offer supervision and further support their understanding of emotional and mental health. For instance, whilst recognising the vital importance of identifying and offering appropriate help to women suffering with depression, she helps midwives to feel more confident about asking the NICE-recommended questions to identify depression by framing them in a more positive way, and to help women cope with depressive thinking by normalising mood changes in pregnancy and helping them to use their own resources for change.
Bindi also works with nurses and midwives based in the neonatal unit at Salisbury District Hospital, who care for over 3,000 families a year. A particular focus has been the neonatal intensive care unit where, every year, about 250 premature or sick babies are nursed. The aims are to help staff manage the very high emotional arousal and stress experienced by the parents of ill babies (some of whom are in intensive care because of the effects of parental addiction), to promote bonding and attachment between parent and baby – and also to learn how to recognise and lower their own high arousal during the highly stressful work that they do. In addition, Bindi provides human givens counselling sessions for pregnant or postnatal women whom midwives refer to her because of depression, anxiety or post-traumatic stress, where support is needed for complex issues.
Enhanced skills
Staff say that they have found their human givens training both professionally and personally valuable. Sometimes, they have absorbed information and learned skills that have completely changed their practice; at other times, it has been more a case of looking at why what they are already doing works, to encourage them to do more of it. We stress that the aim is not to turn them into mental health specialists, thus increasing their workload, but to use some simple techniques, to enhance their practice.
During the training, psychotherapist
Joe Griffin encouraged midwives to view their initial interview with a pregnant woman as, in effect, a therapy session and to conduct it using the simple RIGAAR model used by human givens therapists (rapport building, information gathering, goal setting, accessing resources, agreeing strategies and rehearsing success) to get best results most quickly. Midwives have learned that building rapport is about active listening – letting women express and unload their concerns and summarising these to ensure that they have been heard correctly – rather than challenging or giving advice at too early a stage. Patients are more likely to be receptive to advice about, for instance, stopping smoking, eating less or reducing or stopping alcohol consumption if they feel heard, accepted and respected. But these are aspects of effective communication that can often get rushed or overlooked during consultations. Understanding and helping women deal with addictive patterns of behaviour assists midwives in their public health role of helping women and their families have a healthy lifestyle.
Using imagination
Midwives have also been shown how to use patients’ imaginations to motivate them to change unhealthy behaviours, and to help them experience for themselves that, say, their dreams for their child or their wish to be a healthy active mother and their fears of serious illness are stronger than the desire to eat addictively. (“You can say no to over-eating and yes to life!”) Many of us will know, from our own struggles with excessive behaviours, that willpower emerges without effort when change is positively chosen.
Belief in ability to succeed is crucial, so midwives learn that building on women’s past successes and the skills that they already have, which they can put to use to help them achieve their goals, is time well spent. It is also important, of course, to agree realistic strategies and, in imagination, to rehearse success. Much of this can be achieved in the course of normal booking interviews in early pregnancy.
Midwives have told us that they found learning how to calm down anxious women and agitated partners extremely helpful. Women who have had previous miscarriages or still-births are, understandably, often highly anxious. The clues for how to help are often in the language that they use. One woman, who had had two miscarriages and one stillbirth, used to ring the maternity services every day, complaining that no one was listening to her and seeking re-assurance that her new pregnancy would be fine. By using reflective listening skills, and normalising the many symptoms of pregnancy, midwives enabled this mum-to-be to feel that she was being heard and to recognise how she could feel better in her current pregnancy. She learned that simple breathing techniques could lower her stress and that of her unborn child, and make her more able to hear and act on the advice given to her. She regained confidence in her own capabilities and those of the team in the maternity unit.
Handling panics
Another midwife also reported back to us a specific example of how helpful she had found the 7/11 technique for relaxing (in-breath to the count of 7, out-breath to the count of 11). After learning it, she had seen a highly anxious pat- ient who had apparently been told that, if she kept having panic attacks, she could lose her baby. Unsurprisingly, she was feeling even more anxious and fearful. The midwife taught her the 7/11 technique, used guided imagery to encourage her to visualise a favourite, peaceful place as she relaxed more deeply, and then to see herself eating well, sleeping well, breathing deeply and feeling relaxed and happy. The patient agreed to practise this visualisation often, in her own home. Having something to do that could control, rather than worry about what she mustn’t do, soon stopped the panics.
For staff on the neonatal intensive care unit, learning how emotional arousal can make us stupid, and thus prevent highly stressed parents from understanding seemingly simple communications, has been highly instructive. They have realised that they need to be exceptionally clear with their use of language, to reduce any risk of misinterpretation, and that they need to work at keeping their own arousal down too.