Trust, Relationships and Maternal Mental Health

Why trust is so important when talking about emotions

 Yesterday, Netmums, in association with the Boots Family trust, and Tommys charity, released a report of their research into Perinatal Mental Health. 1500 mums and 2000 health visitors contributed their experiences of symptoms, support, and recovery.

 There were some glaring statistics that came from the report: 30% of mum’s would never tell a professional that they were finding things difficult and 34% of women feared that their baby could be taken away if they admitted any difficulties.  While i recognise that it was also reported that 25% of women would approach a health professional first, other statistics in the report also say that 15% of women experienced their midwives as unfriendly, and a further 23% felt that their midwife or health professional couldn’t help them.

So what does this mean?

Well i don’t believe it means that we have unhelpful midwives in the NHS. Far from it.

Although Midwives report that they do ask either the “whooley questions” (a couple of questions designed to screen for emotional wellbeing struggles) or use the Edinburgh Postnatal Depression Scale (a short questionnaire with the same purpose), they also acknowledge that they struggle to feel confident in talking to mum’s about their emotional wellbeing. They feel more confident discussing their physical health.

Why?

Well i can think of a couple of reasons maybe. The “System”, relationships, and fear of accountability. Well that’s three – but who’s counting?

The System

It is rarely possible for a midwife to remain with a mum throughout her care. Often they work as part of a team, and depending on when your checks are, you may see a different midwife each time you visit your surgery.

Midwives report that there is significant time pressure in the consultation to assess the health of the mum, and the health of the baby, and in an increasingly litigious society i would speculate that this is a main concern, over and above the experience of pregnancy.

Midwives also expressed a concern about the lack of resources in Perinatal mental health, and therefore felt reluctant about opening up a conversation that they didn’t feel able to help with:

In this case, the limitations of the system, produce a barrier to developing good relationships with the women in their care.

Relationships

 Good relationships are key to developing trust. And –importantly – vice versa.

Relationships are two-way. Our expectations of relationships, and whether people will respond to our needs in a helpful way, has roots in our very early experiences of relationships with our own caregivers: These early relationships give us a model, or template, for what to expect from relationships right the way through to our adult lives. If we have had experiences that either people were generally unresponsive to our needs, or inconsistently available to us, then it impacts on the ways in which we feel able to access support. In times of stress and transition, it is these templates that come to the fore most strongly.

What really struck me from the report, was that less than half of the women reported that they would go to their partner first for support. This, I find one of the most important statistics in the whole report (yes, worthy of putting in bold font!). What is it that prevents women from seeking support from the person in their lives who (ideally) shares the most intimate connection with them?

50% of women attributed the main cause of their symptoms to a sense of isolation. (and I think this is the second most important statistic in the report) which may go some way to evidencing the difficulties that women experience in reaching out. Other factors that impacted were traumatic birth, financial or relationship problems, and the experience of an unsettled baby.

Interestingly our culture around perfect parenting, also played into women’s expectations of themselves and experience of mothering. This is something we as women are all responsible for, and needs to change.

By way of evidence, the report also found that the support of loving family and friends, and a bit of time, was just as helpful as any medication (I would argue more helpful in the long run)

Fear of Accountability

 It’s controversial, but for me it’s the ‘elephant in the room’, so I’m going to raise the question: Is one of the barriers to good relationships and communication between a midwife and the woman she cares for, due to fear of knowing?

Outrageous!, I hear you cry, but let me explain.

We’ve already established that the system is a big problem: lack of time, pressure of prioritizing physical health over emotional wellbeing etc.

And, we’ve also talked about how it may come to be that women find it hard to express their emotions.

But is it also hard to hear?

As a Clinical Psychologist, I know through experience that sometimes it can be hard to hear. I know that if it wasn’t for good supervision from other Psychologists (who we use for exploring the impact of other people’s distress on ourselves and our therapeutic relationships with people) then I would find it really hard to hear. What’s more, I’d find it hard to keep asking the questions.

The report found that although every midwife reported that they asked after women’s emotional wellbeing at various stages through their care, only 10% of women were able to recall being asked. Why the discrepancy?

Yes, women may have found it hard to hear that someone was concerned for their welfare – but I can’t accept that 90% of women felt this way. Perhaps also it is possible that Midwives found it hard to ask in the right way, for fear of the response.

I think partly this is because of a death of services for midwives and health visitors to refer on to, but I also wonder whether some of this may be fear of accountability.

What happens for a midwife or health visitor, when the women they are caring for tell them that they are struggling with their emotions? Midwives know the research surrounding the links between anxiety, depression and infant mental health. If they feel there are no other services to refer on to, would they feel that the responsibility therefore lays firmly with them?

Depending on the availability of emotional support for Midwives and health visitors within their role, I would think that the responsibility for a woman’s emotional wellbeing, and potentially the emotional wellbeing of their child, may just be too much to bear. I certainly know that without support in my role, I could find it too difficult.

I don’t think this is wrong. I think it’s human. But it needs addressing.

Conclusions.

 So these are my interpretations of the report. Not fact, just opinon: I would like to see changes in the NHS system where women could be allocated a midwife, spend the time to get to know her, and build a relationship of trust.

I believe there needs to be more emotional support for midwives and health visitors in the role that they do, and more widely available NHS services for Perinatal Mental Health, so that frontline staff do not feel so isolated in their roles in caring for women.

I also would like to see more support antenatally to help women and (ideally) their partners really understand how the transition to parenting may affect them both, and how understanding themselves and their relationships better, will also help them to understand their relationship with their baby (ahem – sorry for the promotion *shuffles feet across the ground* you’ll find more info here ) and make it easier to communicate for support as and when they need it.

 Finally, My heartwarming end to this lengthy blog, is to share with you my recent experience of a twitter conversation between mums around the thread that @MotherAndBaby posted about women’s experience of their Postnatal Depression care, which I think completely encapsulates what we need to find more of.

@littlemissevec in her conversations with both @michelle_c1976, and @monsteratemymum, was kind, supportive and empathic. They talked together briefly about their experiences (within 140 characters!) and most importantly shared the sentiment of support. It goes to show that you can live miles apart, but still find connection with someone who cares. And for that reason, I want to thank communities like Netmums and Mumsnet for giving parents the opportunity to find support, laughter and joint experiences with other parents – even without having to leave the house

I believe that it is fundamentally our connection and trust in others, that really makes us resilient.

Why Attachment Theory is not Attachment Parenting…

Ok so you may be wondering what all the fuss is about Attachment Theory?

If you’ve heard anything about attachment, it may be the controversial arguments about attachment as a parenting practice. Well, the theory is much broader: There is really good clinical evidence to demonstrate how pivotal Attachment Theory is in explaining the neuropsychological development of social and emotional intelligence in our children.

Social and emotional intelligence is fundamentally what underpins our happiness. We live in a culture defined and understood by our relationships with other people. Our ability to trust and rely on these relationships, and have the emotional intelligence to understand other people’s feelings, impacts on our mood, self-esteem, and how we cope with challenges. Ask any business  leader and they will probably agree, our ability to communicate is also fundamental to the achievement of traditional success.

Now ask yourself: If you could choose anything for your child to experience, what would it be?

Health? wealth? happiness? all three? Well i would go so far as to say that Attachment Theory could explain how all three could be considered linked.

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Babies are born into the world completely dependent on their caregiver. They cannot independently find food or shelter. Their only chance of survival is to gain maximal care and proximity from their caregiver.

As a result babies’ brains are tuned into developing relationships with their caregivers: Research shows that babies demonstrate a preference for images of faces, over any other image.

As caregivers, our own neurotransmitter systems are also set up to release and receive chemical messages that promote feelings of affection and bonding behaviour with our babies. Together, the expectation is that a caregiver will feel love and affection for their baby and work hard to protect and nurture them in the best way.

Sometimes, environmental – and neurochemical – factors interrupt this process, and caregivers can find themselves struggling to feel an affectional bond developing between themselves and their baby. As a result, babies develop strategies (referred to as insecure attachment strategies) to either minimise their distress and communications, or intensify their distress and communication, to try and improve the opportunities for the caregiver to sensitively respond.

This is the important bit: ‘Insecure’ attachment strategies are not ‘wrong’ or ‘abnormal’ or ‘pathological’: They are adaptive. They represent the communication style that exists between that parent-infant duo. It’s this ‘style’ that helps them to maintain a relationship with each other.

The pathways or ‘roads’ of experience that develop in our babies’ brains come to represent a kind of template or understanding and expectation of other relationships. In this sense, early sensitive caregiving is likely to lead a baby to expect that all relationships with adults can be trusted to be reliable and available when needed. As a result, these babies are more likely to develop into children who are more able to explore with confidence, and not need the physical closeness of their caregiver as much. This confident exploration gives children abundant opportunities for new experiences. New experiences lead to new pathways, and a wider network of cognitive connections.

Although insecure attachment is adaptive, the effort that goes into maintaining a relationship under difficult environmental and neurochemical circumstances, means that these infants can often develop into children who are either more concerned with the physical closeness of their caregiver, or who have dampened their outward need for connection and caregiving in order to maintain their relationship.  Both of these styles are likely to lead to less interested exploration in what the outside world has to offer, and therefore less value for new experiences, and ultimately less developed cognitive connections.

Without any change in environmental circumstances, our attachment style remains stable into our adult life, and also predicts what we come to expect from our relationship with a romantic partner. If you struggle to trust in the availability of this relationship, it is more likely that you will find it difficult to communicate your feelings in a way that can be easily responded to. It is also likely that your attachment style will continue to impact on your relationship with your baby. This is often how attachment styles can be continued across the generations.

The good news?

No matter what your attachment style (or PP badge), overwhelming research evidence has found that it is not the experiences that have happened in someone’s life that predicts their attachment style, but how they have made sense of them.

There is good evidence to believe that there are different types of secure attachment: Secure attachment that has resulted from sensitive and responsive caregiving; and ‘earned’ security, which has resulted from someone who has been able to create meaning in their experience: They can understand the impact that it has had on their development, and hold a balanced (good and bad) viewpoint about it. This understanding actually encourages the brain to hold greater connections across both brain hemispheres. It is thought that greater connections between the two sides, helps to aid the processing of new situations and relationships, and foster a greater sense of empathy and understanding for how others may be thinking and feeling. In turn we find greater emotional connection with others, including our own children.

Narrative research (research about how people story their lives) has been developing these ideas into many therapeutic techniques that focus on helping adults and children tell stories about their experiences. In turn, they are able to make sense of these experiences in their wider understanding of themselves and others.

If there was only one thing that you could do to try and safeguard your child’s future happiness, then i would suggest that you spend some time reflecting on how your own life experiences have impacted on who you are today – with both strengths and challenges – and how this impacts on your expression of feelings and needs, and your sense of connection with others around you.

If you’d like to find some extra support with this, come and explore here