Wednesday, 3 October 2012

HG Library: Expecting the best: midwifery and the human givens

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.



The NICE guidelines encourage relaxation – and guided imagery is, of course, a wonderful way to elicit it. Midwives learn how valuable it can be to use it during the hour-long session that takes place at around 34 weeks’ pregnancy, to prepare a woman for labour. Evidence has shown that guided imagery before and during labour, in which the woman is helped to focus in her own way on relaxing, staying positive and in control, and coping in whatever circumstances, can help shorten labour3 and reduce or prevent postnatal depression.

Thinking about pregnant women and new mothers in terms of their emotional rather than just their physical needs has empowered midwives enormously. They have responded enthusiastically to the idea of considering ways to provide pregnant women and new mothers with a greater sense of control, for instance. A sense of control, perhaps more than any other, is what may get lost during pregnancy, birth and the postnatal period. Despite claims that women have choice about how and where they give birth, very commonly they do not and this can be frustrating and upsetting. Women are also likely to feel out of control if complications occur during pregnancy or labour. And it is always daunting, of course, to be a first-time mother, when there are too many demands being made that can’t be met and the baby’s needs seem to push out everything else. Women who used to be independent and run successful careers suddenly find themselves feeling totally out of control of their lives. So any kind of control that they can take for themselves is helpful, which is why it is so useful for them to learn how to relax and calm themselves down. Midwives now realise that offering minor choices is meaningful, too – even something as simple as saying, at a home visit after the birth, “Shall I check you first or the baby?” gives back an element of control to a beleaguered new mum.

A lovely house and no friends

Sometimes assumptions may be made that people who seem ‘well off’ in material terms must be emotionally okay, too. But, although families may have lovely homes, they may be isolated and lonely. For instance, we worked with a new mother whose partner stayed in London from Monday to Friday while she struggled to cope alone, separated from her extended family and friends, having suspended her own successful career two weeks before her baby’s birth. In training sessions on emotional needs, Bindi asks midwives to consider different types of families in terms of their emotional needs rather than their physical circumstances, assess which unmet needs might adversely be affecting women’s ability to cope and what they can do to help women meet them. (If women are helped to identify and meet their own emotional needs, they become much more able to develop resilience and not flounder when midwife support comes to an end after the postnatal period.) Bindi also stresses the importance for midwives of keeping their own emotional arousal down, so that they have full access to their thinking brains, when dealing with challenging circumstances.

The very day after one such training session, one of the midwives on the course had a first appointment with a pregnant woman, new to the area, who broke down in floods of tears when she told the midwife that her husband had left her early in her pregnancy. The midwife told Bindi afterwards that, normally, she might have panicked in the face of all that emotion. Instead she concentrated on staying calm and paying full attention to the woman’s concerns and then directed the conversation towards ways that she could get support for herself and meet people. By the end of the session, the woman had decided to join a community art class and was talking in terms of her hopes for the future.

One mother, referred to Bindi for counselling because of depression, connected particularly powerfully with the idea of needs. “So now I understand,” she told Bindi, “why, when my violent first husband did a runner and left me with debts and two young children in a cold flat in London, I didn’t get depressed. I had a purpose – I had to take care of my kids; I was at long last free of fear; and I also had loving family and friends around who helped me in whatever ways they could. But now that I have a lovely new husband and a lovely house in a lovely part of the world – and no friends yet – I see why I do get depressed!”

The value of a smile

Sometimes the solutions are very simple. For instance, midwives may not realise the inestimable value of their smile. But if a midwife is smiling, a pregnant woman is going to feel safer and more confident – just as some people only relax on a plane trip when they see the cabin crew laughing and joking and going about their normal tasks. Also, midwives’ own wealth of experience is itself a resource to be made good use of. It can serve as an effective means of focusing new mothers’ attention when they are nervous or uncertain and encourage them to pay their babies the attention they need, to help both bond together – “Just look at how your baby is looking at you! Believe me, I’ve seen thousands of new mums and babies, and it is so clear that she adores you!”

We have found, since introducing the human givens approach, that a diagnosis of a mental disorder in some pregnant women or new mothers is becoming much less daunting to our midwives. Previously, having seen the word bi-polar or schizophrenia in the notes, they might automatically have assumed that they would be unable to manage that woman’s needs. At the sessions on mental health, midwives are asked to ‘adopt’ a diagnostic label themselves – literally, a sticky label with a diagnosis written on it, which they wear on their lapel for a while. Most find the experience uncomfortable, exposing and excluding, encouraging them to challenge and look beyond the label. They have learned that, just because a certain label is written in someone’s notes, it doesn’t mean that that person will always be anxious or depressed or paranoid. But they might be more likely than the average pregnant woman to get stressed or depressed, and this needs addressing in a normal, human way – “You are looking a little anxious this morning, Maggie. What do you need most right now?” Midwives now know that they can work to help women get their needs met, whatever their diagnosis.

It has been an eye-opener to most that post-natal depression isn’t something intrinsically different from depression; and that a label doesn’t have to be lived with for life. But perhaps one of the most liberating aspects for midwives in learning human givens principles is that they have come to recognise an undervalued resource of their own: their innate knowledge as human beings as well as their learned skills. They have so much medical knowledge and professional experience and are so steeped in all the theory that sometimes they may find it hard to put all that knowledge aside and listen to what women really need from them at a given time. On occasions, it is important to lock up all the training and experience in a mental library and just listen and respond empathically. Sometimes, a touch of a hand or a reassuring smile can be worth much more than useful advice or practical information, which, at that particular moment, a woman is too stressed or distressed even to hear. ■

Caroline Brunt is head of maternity and neonatal services at Salisbury NHS Foundation Trust, a position she has held since 2004. During her midwifery career she developed a particular interest in the psychological wellbeing of mothers and the impact of this on mother and baby bonding and childhood development. She qualified as a human givens therapist in 2001 and has a private therapy practice.

Bindi Gauntlett is a human givens practitioner working from Wiltshire and with in8. Previously, Bindi worked for many years in the NHS as a nurse, health visitor and psychotherapist. She is a Fellow of the Human Givens Institute.

This article was published in Volume 16 No 1, 2009 of the journal, Human Givens.

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Reducing fears of birth

JANE Podkolinski is a senior midwife on the labour ward at Salisbury District Hospital, who supports midwives and mothers after difficult births. Obstetricians also refer to her women who are particularly fearful of forthcoming childbirth, for whatever reasons.

“I was delighted when Caroline introduced the human givens training into our service. It is such common sense. In our work as midwives, we are seeing more and more women whose needs are not met, for whatever reasons, and what I have learned has helped me understand what is happening to them.

“One woman, who was expecting her first baby, was terrified at the prospect of giving birth and was determined to have a caesarean. She had been told that there was no medical reason for her to have one and so, by the time she was referred to see me by an obstetrician at 34 weeks, she was in a highly aroused state. I was exploring ways of helping her to approach birth with confidence when I realised that she felt completely out of control. She had used to feel in charge of how she ran her work and home life and she couldn’t cope with uncertainty. I suggested that she see our human givens counsellor, who would be able to give her helpful strategies for coping, whatever occurred. I also arranged for her to be cared for by one of our community midwife teams, so that she didn’t keep seeing someone new at the hospital and have to keep repeating and further embedding her fears. After one session with the counsellor, she became confident about going into labour.

“Many women do not have strategies for coping with the uncertainties of giving birth and a lot of that is our fault, as professionals, I think. Early in pregnancy, when we test blood, carry out screenings and do scans, we are providing information and thus apparently offering certainty. But we can’t offer certainty about how a birth will be and it is important that women are helped to use their own resources. We routinely use relaxation techniques and guided imagery in the clinic now and we also make good use of our knowledge of pattern matching. So, when we show a woman around the labour ward, we make sure that we don’t go into that room, or enter by that door, if it is associated with a previous bad experience.

“Although, as midwives, we learn to listen, the principles of active listening were new to me. It is crucial that our women feel heard. When we acknowledge how they feel, they don’t have to keep revisiting it. In the case of one woman, who wanted a caesarean because of her fear of a second birth, I listened to her account of her first experience and acknowledged the trauma that she had been through, without jumping in to reassure or advise. Instead, I teased out the positives of that first traumatic experience – for instance, the fact that she had been able to have a normal labour and that the baby had been in the ‘correct’ position for birth. She ended up choosing to have her next baby at home!”

The human givens approach to breastfeeding

AFTER the success of the mental health training, Caroline asked Bindi to work with midwives to support ‘promoting breastfeeding without pressure’. Midwives want to support women in breastfeeding because of its benefits for both mothers and babies. However, they find that women can be put off by what they perceive as the negative aspects: only they can do it; it is tiring and demanding; and other mothers who have breastfed report babies being more wakeful. Bindi has been suggesting to midwives that, sometimes, they might try putting all that they know about the pros and cons of breastfeeding to one side, and relate to expectant mothers simply as ... expectant mothers.

“I suggest that they paint a vivid picture of what it will be like, if all goes well, when a new mother holds her baby for the first time – how she will smell that lovely newborn smell; how she will feel the baby’s incredible softness when it is laid on her tummy moments after birth for her to caress and hold; how she will sense its curiosity and vulnerability and neediness; how sometimes there is an immediate rush of motherly love and awe over the creation of this precious little thing; and how sometimes there is just more of a matching sense of curiosity about who this little person is and who they will in time become. And wouldn’t it be nice, when they are so connected in this special, never-to-be repeated way, with their newborn baby, to offer the breast just this once, and experience how the baby instinctively reaches with its mouth for the nipple, knowing just what it needs, seeking that very sustenance that only a mother can give...

“If a mother can be encouraged to try just once, there is clearly a greater chance that she might choose to do so again. Building on the high emotions and deep wonder and sense of connectedness with their baby after birth may be more meaningful for very many women than pointing out that breastfeeding helps prevent allergies and protects against breast cancer.

"I feel that it is enormously important for midwives not to be driven only by their professional knowledge, when dealing with new mothers at this very special but also very scary time. In a training session recently, we looked at labels and language. Experts in breastfeeding are known as ‘lactation consultants’, a label that can imply to parents that there is a medical problem, as most consultants seen in hospital deal with illness and injury. A new mother hearing that her child may have a ‘dysfunctional suck’ might become so upset to hear that her baby is not perfect that she will not be able to hear or act on anything else that the midwife might say. How midwives respond to breastfeeding concerns and the language that they use in doing so is critical. If a woman is unwilling to breastfeed because she has heard that it makes the nipples sore, she won’t be reassured to be told, ‘Your nipples will only crack and bleed if the baby is not attached properly’. What that tells her is that, if she does experience soreness, then she is at fault – and clearly can’t manage without professional help (immediately taking away both her sense of competence and control). Whilst recognising the wealth of knowledge available to us to support breastfeeding, we would do well to remember that we are the only mammals that seem to ‘need help’ to get it right.

“I recommend using a version of the ‘my friend Jane’ technique: ‘I was working with another woman just last week, who was having exactly the same concerns as you are right now, and then suddenly it just came right ...’ Even when anxious mums deflect all suggestions, saying, ‘I’ve tried that. I’ve tried that. I’ve tried that,’ it can still help to say, ‘I’ve known other new mothers who felt that they had tried everything and were close to despair and then they just allowed themselves to take a mental step back – and found a way.’

REFERENCES 

1. Confidential Enquiry into Maternal and Child Health (2007). Saving Mothers’ Lives 2003–2005: reviewing maternal deaths to make motherhood safer. CEMACH.

2. National Institute for Health and Clinical Exellence (2007). Antenatal and postnatal mental health: NICE guidelines. NICE.

3. Jenkins, M W and Prichard, M H (1983). Hypnosis: practical applications and theoretical considerations in normal labour. British Journal of Obstetrics and Gynaecology, 100, 221–6.

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