An exploration of the use of family therapy in a Perinatal Infant Mental Health Service

Perinatal Infant Mental Health (PIMH) is a field that focuses on enhancing early parent-infant relationships. The perinatal period is defined as pregnancy and the first postnatal year². These early days of an infant’s life are crucial for brain development; disturbances in early parent-infant relationships can impact negatively upon the child’s development.

It is thought that there is a link between a lack of practical and emotional support for a mother and the incidence of maternal postnatal depression. A partner’s support and encouragement are understood to be vital in the management of maternal postnatal depression³. Ninety-two percent of couples report increased conflict after the birth of a child^4,5. This is likely to impact upon family functioning and may exacerbate mental health symptoms. The perinatal period may be a time when issues from childhood and the past re-emerge, and difficulties in a relationship with parents can often be re-awakened as a woman prepares for parenthood.

Clinical Practical Guidelines⁶ for mental health disorders occurring in the perinatal period put emphasis on taking a family-centred approach when working with women with mental health vulnerabilities or difficulties in their relationship². Despite this, minimal literature exists on working from a systemic family therapy frame in the PIMH field, with existing literature favouring the mother-infant dyad⁷.

Due to this dearth of available research, a small, qualitative study was undertaken with five clinicians from a PIMH service in a metropolitan area. The clinicians participated in a focus group related to four key systemic concepts: genograms, family of origin, transitions and morphogenesis.

The findings suggest that:

• Whilst emphasis is placed on the changing roles occurring within the family expansion phase (arrival of children), there was little mention of other members of the family system, such as parental siblings who become aunts/uncles;
• There appears to be a lack, both from the results and also the PIMH literature, of an exploration of family of origin for the father.

Unexpected findings:

• PIMH interventions occurring once the baby was born often included a discussion about the roles in caring for the baby. This also provided an opportunity for focus-group participants to support clients to elicit increased support from their family or to enforce boundaries to enhance their own sense of functioning as a mother;
• An apparent theme was the inconsistency among participants in identifying who their client is. This was considered a barrier with treatment implications.

PIMH sits between the fields of attachment and mental health. Each has a different focus on who the identified client is, and the length of service involvement. Service operating hours may also determine which family members can engage meaningfully with the service. These factors may shed light on the broader societal views of caregiving. Family therapists have the opportunity to engage fathers and other significant family members at the outset of the intervention, which is likely to increase their feelings of validation and support so that they may be more amenable to change.

Recommendations for family therapists:

• Engage fathers and/or significant others at the outset of the intervention to increase the likelihood of achieving systemic change;
• Proceed with caution and curiosity when exploring a client’s family of origin. Pregnancy is often a time when families are motivated to change and this can make proactive and client-centred work more possible. Practitioners should work at the client’s pace, given that pregnancy can also be a time of increased vulnerability;
• Use systemic knowledge to educate families on the complexities of the transition to the new lifecycle and the ripple effects on broader family functioning.

References

¹ White, J. (2018) Does a Perinatal Infant Mental Health Team Hold the Family in Mind? Opportunities and Challenges for working Systemically in this Specialised field, Australian and New Zealand Journal of Family Therapy, 39 (2), 144-154.
² Beyondblue (2011) Clinical practice guidelines for depression and related disorders—anxiety, bipolar disorder and puerperal psychosis—in the perinatal period. A guideline for primary care health professionals. Melbourne, Australia: Beyondblue: The national depression initiative.
³ NSW Department of Health (2009) NSW Health/Families NSW Supporting Families Early Package – SAFE START Guidelines: Improving mental health outcomes for parents and infants, NSW Department of Health.
⁴ Post and Antenatal Depression Association (2010) Postnatal Depression. Retrieved http://www.panda.org.au/
⁵ Taylor, E. (2011) Becoming us: The Essential Relationship Guide for Parents. Sydney, NSW: Harper Collins Publishers.
⁶ Revised Perinatal Clinical Practice Guidelines have been developed by the Centre of Perinatal Excellence (COPE). The new guidelines, titled ‘Effective mental health care in the perinatal period: Australian Clinical Practice Guidelines’ were released late October 2017. Download the Perinatal Clinical Practice Guidelines
⁷ McHale, J.P. (2007) When Infants Grow Up in Multi-Person Relationship Systems, Infant Mental Health, 28 (4), 370-392.