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How babies and a narrative of recovery might help mothers who experience postpartum psychosis

The role of the baby as both the cause and agent of recovery for women suffering from postpartum psychosis is part of the clinical and research work of Triple P Research Network member Dr Anja Wittkowski.

Two qualitative studies at the centre of this work were presented at the World Congress of Behavioural and Cognitive Therapies in Melbourne last month.

Dr Wittkowski’s research focuses on a time when most women anticipating the arrival of their baby are hoping to feel wonderful. But some may find themselves frightened, confused and, more than likely, sectioned under their country’s relevant Mental Health Act.

Dr Anja Wittkowski

Dr Anja Wittkowski

Rare but rapid onset

“Postpartum psychosis is quite rare, with around one in 1000 mothers giving birth experiencing it,’’ Dr Wittkowski said during a recent visit to UQ’s Parenting and Family Support Centre, following the World Congress. “It usually comes on very quickly within a few days of giving birth and it almost always requires an inpatient admission.

“It is an incredibly significant life event which can make the women who experience it question their very identity. But my impression is that many of these women go on to live normal, fulfilling lives as both women and mothers.’’

Dr Wittkowski said any pregnant woman could be at risk of developing the condition but an underlying bipolar disorder, or a previous postpartum psychosis, appears to increase the risk of experiencing it.

Dr Wittkowski is a senior lecturer in clinical psychology at The University of Manchester, the current Research Director for the Clinical Psychology Doctorate program at The University of Manchester as well as a clinical psychologist at the 10-bed Mother and Baby Unit (MBU) on Andersen Ward at Wythenshawe Hospital operated by the Manchester Mental Health and Social Care Trust.

Mothers who are admitted to Andersen Ward may be experiencing problems such as postnatal depression, postpartum psychosis or an exacerbation of an existing mental health problem, such as psychosis or bipolar affective disorder.

Dr Wittkowski’s first study involved conducting qualitative interviews with 12 women and was aimed at developing a theoretical understanding of recovery from psychosis following childbirth. This study was published in the journal BMC Psychiatry.

“We know from our first study that the first step in recovering from a postpartum psychosis is gaining an initial understanding of what you have experienced,’’ Dr Wittkowski said. “We know someone has a sense of realisation when they ask their friends or family, ‘what did I say, what did I do’, and can’t believe they did what their friends and family are telling them they did.

“Once they realise that they had very unusual (often psychotic) experiences, these women experience a great sense of loss. They had been anticipating that after giving birth they were going to experience the best feeling in the world but the next minute they are frightened and confused.

Losing a piece of themselves

“This period of experiencing acute psychotic symptoms is not viewed by these women as representative of what they are normally like. As part of recovery, they have told us that they had to accept that they have lost a little bit of themselves, such as their sense of security, their knowledge of being a stable persoverticle babyn or just time. But the women we interviewed told us that they used those experiences positively.

“In my clinical experience I can begin to see women recover when they start to develop a narrative about their experiences, partly as a way of explaining to others what happened to them – and why they had to b
e admitted to a psychiatric unit – but mostly so they have a way of explaining those very unusual experiences to themselves.’’

One of the women I worked with expressed this process of acceptance really nicely. She told me that she really liked musical animation. She explained that during her acute illness phase she was found hiding away in her room but singing these songs. She later said to me that singing these songs ‘helped me through the darkest moments in my life’.”

Because of the importance of psychosocial factors in the role of recovery, Dr Wittkowski said the research team asked the women in their first study about the things that had helped their recovery and the women identified that their relationships with family members and mental health staff had been very helpful.

“When these women talked about their relationships with others, one very strong theme emerged: none of these women mentioned their baby,’’ Dr Wittkowski said. “We were thinking about how odd that was and that informed the design of the second study. As the baby is a reason why women become extremely unwell in the first place, we wanted to know about the role of the baby in their recovery from postpartum psychosis.

Mothers who took part in the second qualitative study told us that the baby is central to their recovery and the baby was perceived a facilitator but the baby was also a barrier to recovery. These findings reflected what we had seen in clinical practice on the unit.

“The mothers also told us they felt they had to sacrifice their own wellbeing for the sake of the baby.’’

The second as yet unpublished study underlined the value of the work of the Mother and Baby Unit which centres around mothers’ wellbeing but also encouraging mothers to look after their babies and bond with them.

“We know that by looking after the baby, these women achieve a greater sense of self-confidence which helps their recovery,’’ she said.

Baby Triple P

Dr Wittkowski and fellow researchers are about to embark on a new study in which the Baby Triple P program will be offered at the Mother and Baby Units in Birmingham and Manchester. Funded by a National Institute of Health Research for Patient Benefit grant in the UK, they will be working with women who have been admitted for a range of mental health difficulties, including psychosis, postnatal depression, having thoughts of harming their child, stress, bonding problems, or existing problems, such as OCD, anxiety and/or depression.

“Baby Triple P just fits in so well with what we are doing,’’ Dr Wittkowski said. “When I first came across Baby Triple P I liked the fact that it had two sessions on dealing with the relationship between mother (or parent) and baby, two sessions for coping and building social support and four sessions for skill implementation via phone support.

“It’s really nice that there are four weeks of phone support so we get to see how the women manage the transition from having been on the unit to being back at home.”

“When we ran our mini-pilot, one of the women told me she really liked the idea of knowing that she could ring me after having been discharged from the Mother and Baby Unit.

“The study is a feasibility study looking at the possibility of recruiting women in this setting, whether they would be ok with being randomly allocated to treatment as usual plus the intervention or treatment as usual only and whether we can retain them throughout the study.’’

 

 

 

 

 

 

First randomised trial of a parenting program in mainland China shows Group Triple P has a positive impact on children’s academic lives

shutterstock_276608939A paper published in the journal Behavior Modification explores whether the development of more westernised parenting practices in China over the past four decades would mean that western-developed parenting programs would be effective with Chinese families.

The randomised controlled trial of Group Triple P, the first RCT of a western-developed parenting program in mainland China, found that Group Triple P significantly improved dysfunctional parenting and parental adjustment, increased parents’ confidence and reduced child adjustment problems.

The introduction of Triple P to Shanghai parents of children from grades one to three who were worried about their child’s schooling also sought to find out if Triple P could have a positive impact on children’s academic lives.

The findings suggest that may be the case, with participation in Group Triple P leading to parents becoming more satisfied with their child’s academic performance and the children showing less problem behaviours related to learning, according to the parents.

All effects were maintained six months after the parents participated in the program.

Academic performance

Former PhD student of the Parenting and Family Support Centre at The University of Queensland, Dr Mingchun Guo, said that improved parental satisfaction in academic performance may have been brought about because parents had adjusted their expectations of their children and had become more accepting of their academic achievement. Alternatively, there may have been an actual change in the child’s academic achievement.

“Unfortunately, we were not able to measure academic performance directly in this study, although a recent 15-year follow-up study in Western Australia indicated Group Triple P , when delivered to parents of children aged at 3 to 4 years, produced sustained improvements in children’s literacy and numeracy scores once at school.’’

The Chinese study was also a rare attempt to investigate parenting changes from the child’s perspective, with children reporting that their parents used significantly more positive parenting practices after participating in Group Triple P. However, Dr Guo cautioned that more research was needed to explore children’s views on changes in parenting practices.

The study found no change on children’s reports of corporal punishment in the home either at post-intervention or six-month follow-up, however, Dr Guo suggests this may have been caused by a floor effect due to the low average level of corporal punishment reported by parents in the study.

“Triple P encourages nurturing, engaging, consistent, and assertive parenting; hence, it coaches authoritative parenting,’’ Dr Guo writes. “As recent research has shown that Mainland Chinese parents endorse authoritative parenting and this is positively related to children’s social and school adjustment, it is not surprising that Group Triple P had positive effects on a range of parent and child outcomes in this study.’’

In introducing the study, Dr Guo places parenting in the context of the drastic changes in economy, education, family structure and family lives that China has experienced in the past four decades.

Confucian philosophy and filial piety

He said Confucian philosophy and values such as filial piety, or respect for one’s parents, had played a major role in Chinese parenting practices with Chinese parents typically depicted as emphasising the need for parental authority and obedience from children.

But such attitudes may have relaxed to some extent with suggestions that the one-child policy, for example, had led to Mainland Chinese parents becoming more indulgent with their children.

A recent empirical study also found that Mainland Chinese parents predominantly endorsed authoritative rather than authoritarian parenting, they emphasized egalitarian and the two-way parent-child relationship and were warmth-oriented rather than control-oriented toward their children.

Dr Guo writes that these findings on parenting styles were substantially different than those found in studies conducted one and two decades previously, suggesting Chinese parenting practices had become more similar to Western-style parenting.

In this context, it was likely that Mainland Chinese parents, particularly those in urban areas, would accept and use parenting strategies from a Western-developed program. This particular trial suggests that this may well be the case.