What’s the idea?

There may be a range of people in the mother’s family and wider support network who are important to her mental health and may be able to contribute to her recovery, as well as needing support themselves.

Mapping the family is an opportunity to consider relevant family members’ interpersonal experiences, including any experiences of perinatal loss.

Why implement it?

Mapping can:

• identify the people who the mother relies on for support
• give clinical indications about the focus of the intervention, such as family therapy or couple work that directly involves others
• form the basis for providing joined-up care between services (see Idea #10: Partnership working and transitions)
• provide information about interpersonal traumas such as loss or abuse which may impact on mental health and recovery.

Actions to consider

• Explore who is in the mother’s family and support network, at the earliest opportunity.
• Regularly ask questions about the family system throughout the mother’s involvement with the service, as key relationships and wishes may change.
• Hold in mind that mothers may not want others involved or may feel conflicted about their involvement, particularly if coercive control features in their relationships.

Perinatal loss

Some mothers, partners or other family members may have experienced pregnancy loss or the death of a baby before or during the current episode of care. Regardless of gestation, age, or reason, such losses can exacerbate pre-existing mental health disorders or precipitate new mental health difficulties.

Any parent who has experienced perinatal loss is at increased risk of depression, anxiety disorders, including tokophobia (extreme fear of childbirth) and birth-related trauma. Although grief itself should not be pathologised, it is important to ensure that mental health needs and symptoms are not mistakenly attributed to grief

Practice example: Staying curious about the family

Coombe Wood Mother and Baby Unit (MBU), Central and North West London NHS Foundation Trust

Coombe Wood MBU is committed to a “think family” approach. Recognising that supporting families can help mothers to recover quicker, the unit aims to support partners and other family members in order to enable the mother’s recovery whilst also helping families achieve their best level of functioning.

They feel it is important that families hear this message from the first contact with their service. Mothers are told that “we work with you and your family” when they arrive at the MBU, and staff see the family within 72 hours of the mother’s admission.

They use a genogram approach to explore the mother’s support network, using questions such as: “Who is in your family?” “Is there anyone who supports you?” “Are there any difficulties in your family or friendships at the moment?” These can be followed by questions such as “Would you like them to be here?” Staff find this approach helps make sense of what has happened prior to admission.

The information generated enables them to develop clinical formulations and treatment plans that take these factors into account, potentially locating the ‘problem’ outside the mother in the wider system. This then determines the type of support and treatment offered to the mother and her family, such as family therapy, couple-focused work, or one-to-one support for mothers.

If supportive others are not identified by the mother, staff note who does and doesn’t visit and use these observations to start conversations about support networks.

When a mother does not want others involved in her care, staff explore this and whether ruptures in relationships may be contributing to her current difficulties, to identify where it may be helpful for repairs to be made. If partners and other family members are not directly involved in the mother’s care, staff ensure that they are held in mind throughout.

Asking about domestic violence and abuse (DVA)

While working with families it is important to be aware that:

• One in four mothers in contact with mental health services may be experiencing violence, abuse and coercive control.
• DVA often starts or intensifies in the perinatal period.

What is DVA?

In the UK it is defined as: ‘Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological, physical, sexual, financial, and emotional’ [ref. 13].

The Department for Work and Pensions launched a national Reducing Parental Conflict Programme to support implementation of evidence-based interventions. Local authorities have since been working to increase provision to tackle parental conflict.

Confidentiality and consent to inform and involve others

Once the family structure has been explored and mapped with the mother, it is important to seek consent from the mother about who can be involved and informed about her care, and how much information can be shared (full, partial or no information).

These decisions also need to be clearly documented in the mother’s notes.

Actions to consider

Services should:

• assess the mother’s capacity to consent to sharing information. If she does not have capacity, then follow local safeguarding and Mental Capacity Act policies. A clinical decision will need to be made about whether it is in the mother’s and baby’s best interests to involve others
• fulfil the duty to share specific information relating to the baby’s care and wellbeing with the other parent, if there is shared parental responsibility for the baby. This may be particularly important if the mother’s mental health disorder is affecting her ability to provide care for the baby
• once consent has been provided to make contact and/or share information, ensure this is done.

Services could:

• consider whether generic information can be shared without breaching confidentiality, if consent is not given to share specific details. For example, if a mother does not want information about her health or care to be shared with her partner or family member, can general information be provided on mental health disorders?
• check whether there is an advance decision in place about who should be involved and how, if the mother’s current capacity or decision-making is impaired
• encourage the mother to make an advance decision about involving others if she is currently well enough, which may be helpful if her symptoms deteriorate or she becomes unwell again in the future
• be aware that if a mother is experiencing delusions these may involve her partner or other family members. This may result in her refusing contact or consent from them to be involved in her care. Although this can be very upsetting and destabilising for the family, the mother’s wishes should be adhered to, subject to any advance decisions. Safeguarding policies must be complied with at all times. It may take some time to establish whether the mother’s concerns about a family member are due to a delusion or a reality. The partner or family member may feel excluded and under suspicion. Take care to sensitively gain objective perspectives, where possible
• hold the whole family in mind when developing care plans, even if the mother has not consented for the family to be directly involved. The care plan may have implications for the family, such as planning leave or discharge back home. Discuss with the mother whether and how to involve the family for these aspects of the care plan
• check consent decisions periodically, because consent is a dynamic process and feelings about others may change over the course of the mother’s contact with services.