Perinatal healthcare for women at risk of children's social care involvement: a qualitative survey of professionals in England.

BACKGROUND: Women with complex health needs are more at risk of having children's social care involvement with their newborns than other mothers. Around the time of pregnancy, there are opportunities for health services to support women with these needs and mitigate the risk of mother-baby separation. Yet little is known about healthcare professionals' experiences of providing this support. METHODS: We administered an online survey to perinatal healthcare professionals across England (n=70 responders), including midwives, obstetricians, perinatal psychologists/psychiatrists and health visitors. We asked about their experiences of providing care for pregnant women with chronic physical conditions, mental health needs, intellectual/developmental disabilities and substance use disorders, who might be at risk of children's social care involvement. We conducted a framework analysis. RESULTS: We constructed five themes from participant data. These include (1) inaccessible healthcare for women with complex needs, (2) the challenges and importance of restoring trust, (3) services focusing on individuals, not families, (4) the necessity and caution around multidisciplinary support and (5) underfunded services inhibiting good practice. CONCLUSIONS: Women who are at risk of children's social care involvement will likely experience perinatal healthcare inequities. Our findings suggest that current perinatal healthcare provision for this population is inadequate and national guidelines need updated to inform support.

Experiences of parent-infant teams among mothers diagnosed with perinatal mental health difficulties.

BACKGROUND: Disrupted parent-infant bonds can have a negative impact on childhood development. In the United Kingdom, parent-infant teams can offer support to parents (most commonly mothers) to help strengthen parent-infant relationships. However, little is known about women's experiences of these teams. This study aimed to explore experiences of support from parent-infant teams among mothers diagnosed with perinatal mental health difficulties. METHOD: Qualitative semi-structured interviews were conducted with eleven mothers who had had been referred to and/or accessed a National Health Service parent-infant team. Interviews were analysed using thematic analysis. RESULTS: Women reported occasional difficulties accessing parent-infant services, particularly when they were left to contact services/follow up referrals themselves. However, once accessed mothers valued consistent, regular support with a therapist who was empathic and accepting of their difficult feelings. Some women saw therapists as resembling 'mother figures' and appreciated a feeling of being cared for. However, at times women felt there was an overemphasis on the role of the mother and mother-infant bond, and a disregard of fathers and other family members. CONCLUSION: Our study demonstrates that mothers value support from parent-infant teams. However, clinicians need to ensure they do not inadvertently reinforce problematic gender norms and narratives when offering support.

Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis.

INTRODUCTION: The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood. AIM: To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN. METHODS: Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies. RESULTS: Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate. DISCUSSION: Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis.

BACKGROUND: There is a recognised need to develop clear service models and pathways to provide high quality care in the community for people with complex emotional needs, who may have been given a "personality disorder" diagnosis. Services should be informed by the views of people with these experiences. AIMS: To identify and synthesise qualitative studies on service user experiences of community mental health care for Complex Emotional Needs. METHODS: We searched six bibliographic databases for papers published since 2003. We included peer reviewed studies reporting data on service user experiences and views about good care from community-based mental health services for adults with CEN, including generic mental health services and specialist "personality disorder" services. Studies using any qualitative method were included and thematic synthesis used to identify over-arching themes. RESULTS: Forty-seven papers were included. Main themes were: 1) The need for a long-term perspective on treatment journeys; 2) The need for individualised and holistic care; 3) Large variations in accessibility and quality of mental health services; 4) The centrality of therapeutic relationships; 5) Impacts of 'personality disorder' diagnosis. Themes tended to recur across studies from different countries and years. DISCUSSION: Recurrent major themes included wanting support that is individualised and holistic, provides continuity over long journeys towards recovery, and that is delivered by empathetic and well-informed clinicians who are hopeful but realistic about the prospects of treatment. Care that met these simple and clearly stated priorities tended to be restricted to often limited periods of treatment by specialist "personality disorder" services: generic and primary care services were often reported as far from adequate. There is an urgent need to co-design and test strategies for improving long-term support and treatment care for people with "personality disorders" throughout the mental health care system.

A qualitative investigation of models of community mental health care for women with perinatal mental health problems.

BACKGROUND: Specialist community perinatal mental health teams support women diagnosed with moderate to severe psychiatric difficulties in pregnancy or postnatally. These teams are being expanded across the UK, and there is considerable international interest in this model of care. However, not all women access these teams, and many are instead supported by community mental health services that do not specialise in the perinatal period. AIMS: To explore perinatal women's experiences of specialist perinatal versus generic non-perinatal community mental health support. METHODS: Semi-structured interviews were conducted with 36 women diagnosed with perinatal mental health difficulties who were supported in the community either by a specialist perinatal or general non-perinatal mental health service. Data were analysed thematically. RESULTS: Women felt that specialist perinatal and non-perinatal services alike were under-resourced and somewhat too narrow in their remit, but reported positive experiences across both settings. They particularly valued the specialist expertise offered by perinatal teams, but also valued greater continuity of care over a longer period, which some non-perinatal teams provided. CONCLUSIONS: The findings suggest that women who experience perinatal mental health difficulties value specialist perinatal expertise, but that general, non-perinatal teams may also have advantages for some. Further research into optimal care arrangements is merited.

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses.

PURPOSE: The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. METHODS: We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. RESULTS: We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. CONCLUSION: Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

Experiences of intensive home treatment for a mental health crisis during the perinatal period: A UK qualitative study.

Some women with severe perinatal mental health difficulties in England are cared for by acute home treatment services, known as Crisis Resolution Teams (CRTs), which provide short-term home-based treatment for adults experiencing a mental health crisis. Intensive home treatment has been trialed in a number of countries, but it is not known how well suited it is to the needs of perinatal women. This qualitative study aimed to explore how women and practitioners experience the provision of intensive home treatment for perinatal mental health problems. Semi-structured interviews were conducted with women who had received intensive home treatment in the perinatal period (n = 15), and focus groups were held with practitioners working in CRTs or in specialist perinatal mental health services (3 groups, n = 25). Data were analysed thematically. Women commonly found intensive home treatment problematic, experiencing it as intrusive and heavily risk-focused, with poor staff continuity and little tailoring to the perinatal context. However, women valued emotional support when provided, particularly when it had a perinatal focus, sometimes based on practitioners sharing their own experiences. Some women also appreciated avoiding hospital admission, but choice was often limited. Practitioners reported a lack of perinatal training among CRT staff and described difficulties tailoring treatment to perinatal women's needs. Currently, intensive home treatment, as offered by CRTs, may not be well suited to women with perinatal mental health difficulties. Findings suggest a need to develop community crisis responses that are better tailored to the needs of this population.

A qualitative comparison of experiences of specialist mother and baby units versus general psychiatric wards.

BACKGROUND: Mother and baby units (MBUs) are an inpatient mental health service where women experiencing acute severe postpartum psychiatric difficulties can be admitted with their babies. They are currently viewed as best practice in the UK and elsewhere. However, as service provision is fragmented, some women residing in areas without MBUs are admitted to acute general psychiatric wards without their infants. This study aimed to compare qualitatively experiences of these two service types from the perspectives of women and clinicians. METHODS: Semi-structured interviews were conducted with fifteen women who received treatment for perinatal mental health problems on a general psychiatric ward and/or MBU in England. Two focus groups were also conducted, one with MBU staff (n = 11) and one with acute ward staff (n = 6). Data were analysed thematically. RESULTS: Women generally preferred being co-admitted with their baby to an MBU over lone admission to a general psychiatric ward. Women and clinicians felt that MBUs provided more perinatally-focused, family-centred care, and were better-equipped to meet women's needs. General wards were reported by women and staff to lack the necessary facilities and expertise to support perinatal women adequately, while separation of mothers and babies was often experienced by women as traumatic and detrimental to recovery. However, some areas for improvement were also identified across both service types, particularly relating to difficulties transitioning home post-discharge, inadequate support for family members, staffing issues and access problems (with MBUs). CONCLUSIONS: Findings suggest that specialist perinatal inpatient care is considered preferable to generic care in the perinatal period from both service user and staff perspectives. Increased collaboration between perinatal and non-perinatal services could help improve perinatal expertise on general psychiatric wards, while further expansion of perinatal services (e.g. to cater for women currently considered too high risk for MBUs and for those discharged from inpatient settings) could tackle other shortfalls in care.

Experiences of social work intervention among mothers with perinatal mental health needs.

Perinatal mental health difficulties are prevalent among women, and the vulnerability of young infants makes this a time when families experiencing multiple adversities may be particularly likely to attract state intervention. However, very little is known about how mothers experience social work intervention during the perinatal period. This study explored experiences of social work intervention among women with perinatal mental health difficulties. Qualitative semi-structured interviews were carried out with 18 women with 6- to 9-month-old babies, who had been treated in England for a perinatal mental health difficulty and also had social services intervention. Interviews were analysed using thematic analysis. Findings suggested that mothers had a predominantly negative view of children's social services, especially when social workers had significant child protection concerns. The fear of being judged an unfit mother and having their babies taken away overshadowed their encounters. Mothers felt that social workers would not accept they could be good mothers in spite of their difficulties and set them up to fail. Some felt that social workers focused exclusively on the risks to the baby and did not acknowledge the mother's own needs or understand perinatal mental health. In some cases, social work intervention was described as intensifying pressure on mothers' mental health, leading to escalating difficulties and increased likelihood of care proceedings. At the same time, our study also included examples of mothers forming positive relationships with social workers, and of 'turning points' where initially negative interactions stabilised and child protection concerns lessened. Women's accounts highlighted the importance of feeling 'known' by social workers who understood and respected them. The findings also suggested there may be value in improving collaboration between social workers and mental health professionals to create more space for representation of women's needs as well as those of their babies.

Experiences of how services supporting women with perinatal mental health difficulties work with their families: a qualitative study in England.

OBJECTIVES: Partners and wider family members play a vital role in relation to women's perinatal mental health. Clinical guidelines in the UK and internationally recommend that services supporting women with perinatal mental health difficulties involve and support their families too. However, little is known about family members' needs and experiences, or whether they feel included by mental health services. This study set out to explore this. METHODS: This research formed part of a wider study exploring experiences of perinatal mental health care in England. The broader study included semi-structured interviews with 52 women across England who received treatment for a perinatal mental health difficulty, and 32 family members identified by the women as offering them some support. Data from these 84 interviews relating to how services work with partners and families were extracted and analysed thematically. RESULTS: Analysis identified three overarching themes: (1) the centrality of women's families to their perinatal mental health/access to support, (2) experiences of partners and families being excluded by services and (3) ambivalence among women and their families about increasing family involvement/support. We found that partners and families appear to have an important influence on women's perinatal mental health, access to care and interactions with services, but that services tend to focus on individual women (and babies) with little regard for their wider family context. The complexity of involving and supporting partners and families, coupled with anxiety about this among women and their families, reinforces the tendency to marginalise them. CONCLUSION: Involving women's families and providing the support they need is challenging, but important. Experiences of women and their families of services treating perinatal mental health difficulties suggests greater focus is needed on overcoming barriers to family inclusion and on challenging underlying gender roles and expectations, rather than allowing these to shape and guide practice.

How do women's partners view perinatal mental health services? A qualitative meta-synthesis.

OBJECTIVES: Perinatal mental health difficulties are prevalent among women and can adversely affect their partners too. There is also increasing recognition that a woman's partner can play a vital role in relation to her perinatal mental health and should be supported and involved in decisions about her care. Yet it is unclear how services are experienced by the partners of women with perinatal mental health difficulties. This study aimed to synthesize qualitative evidence of partners' views of perinatal mental health care. METHODS: A systematic search of 5 electronic databases identified 20 studies that met the inclusion criteria. The findings of these studies were synthesized using an approach based on meta-ethnography. RESULTS: Six themes were identified, namely, the marginalization and neglect of women's partners, an unmet need for information, partners' ambivalence about involvement and support, practical barriers to involvement, views about support for women's partners, and the impact on partners of the care women received. CONCLUSIONS: Given the importance of women's partners in relation to perinatal mental health as well as to women's engagement with support and treatment outcomes, greater consideration should be given to their needs to ensure they feel well informed and involved in perinatal mental health care, rather than marginalized. However, professionals also need to challenge the barriers to involvement and support that women's partners face and consider the ways in which services may reinforce these barriers.

What is compassion and how can we measure it? A review of definitions and measures.

The importance of compassion is widely recognized and it is receiving increasing research attention. Yet, there is lack of consensus on definition and a paucity of psychometrically robust measures of this construct. Without an agreed definition and adequate measures, we cannot study compassion, measure compassion or evaluate whether interventions designed to enhance compassion are effective. In response, this paper proposes a definition of compassion and offers a systematic review of self- and observer-rated measures. Following consolidation of existing definitions, we propose that compassion consists of five elements: recognizing suffering, understanding the universality of human suffering, feeling for the person suffering, tolerating uncomfortable feelings, and motivation to act/acting to alleviate suffering. Three databases were searched (Web of Science, PsycInfo, and Medline) and nine measures included and rated for quality. Quality ratings ranged from 2 to 7 out of 14 with low ratings due to poor internal consistency for subscales, insufficient evidence for factor structure and/or failure to examine floor/ceiling effects, test-retest reliability, and discriminant validity. We call our five-element definition, and if supported, the development of a measure of compassion based on this operational definition, and which demonstrates adequate psychometric properties.

The Effectiveness of Mindfulness-Based Interventions in the Perinatal Period: A Systematic Review and Meta-Analysis.

Perinatal mental health difficulties are associated with adverse consequences for parents and infants. However, the potential risks associated with the use of psychotropic medication for pregnant and breastfeeding women and the preferences expressed by women for non-pharmacological interventions mean it is important to ensure that effective psychological interventions are available. It has been argued that mindfulness-based interventions may offer a novel approach to treating perinatal mental health difficulties, but relatively little is known about their effectiveness with perinatal populations. This paper therefore presents a systematic review and meta-analysis of the effectiveness of mindfulness-based interventions for reducing depression, anxiety and stress and improving mindfulness skills in the perinatal period. A systematic review identified seventeen studies of mindfulness-based interventions in the perinatal period, including both controlled trials (n = 9) and pre-post uncontrolled studies (n = 8). Eight of these studies also included qualitative data. Hedge's g was used to assess uncontrolled and controlled effect sizes in separate meta-analyses, and a narrative synthesis of qualitative data was produced. Pre- to post-analyses showed significant reductions in depression, anxiety and stress and significant increases in mindfulness skills post intervention, each with small to medium effect sizes. Completion of the mindfulness-based interventions was reasonable with around three quarters of participants meeting study-defined criteria for engagement or completion where this was recorded. Qualitative data suggested that participants viewed mindfulness interventions positively. However, between-group analyses failed to find any significant post-intervention benefits for depression, anxiety or stress of mindfulness-based interventions in comparison to control conditions: effect sizes were negligible and it was conspicuous that intervention group participants did not appear to improve significantly more than controls in their mindfulness skills. The interventions offered often deviated from traditional mindfulness-based cognitive therapy or mindfulness-based stress reduction programmes, and there was also a tendency for studies to focus on healthy rather than clinical populations, and on antenatal rather than postnatal populations. It is argued that these and other limitations with the included studies and their interventions may have been partly responsible for the lack of significant between-group effects. The implications of the findings and recommendations for future research are discussed.

The effectiveness of self-help mindfulness-based cognitive therapy in a student sample: a randomised controlled trial.

Mindfulness-based cognitive therapy (MBCT) involves approximately twenty hours of therapist contact time and is not universally available. MBCT self-help (MBCT-SH) may widen access but little is known about its effectiveness. This paper presents a randomised controlled trial (RCT) of MBCT-SH for students. Eighty students were randomly assigned to an eight-week MBCT-SH condition or a wait-list control. ANOVAs showed significant group by time interactions in favour of MBCT-SH on measures of depression, anxiety, stress, satisfaction with life, mindfulness and self-compassion. Post-intervention between-group effect sizes ranged from Cohen's d = 0.22 to 1.07. Engagement with MBCT-SH was high: participants engaged in mindfulness practice a median of two to three times a week and 85% read at least half the intervention book. Only 5% of participants dropped out. This is the first published RCT of MBCT-SH and benefits were found relative to a control group. MBCT-SH has the potential to be a low-cost, readily available and highly acceptable intervention. Future research should include an active control condition and explore whether findings extend to clinical populations.