Prof Heather O'Mahen and Dr Sarah Healy on CBT for anxiety and depression in the perinatal period
In this episode of Let's Talk About CBT- Practice Matters, host Rachel Handley is joined by two leading experts in perinatal mental health- Professor Heather O'Mahen and Dr Sarah Healy. Together, they explore the unique challenges, adaptations, and opportunities that come with providing effective CBT for individuals during the perinatal period. Heather and Sarah draw on their clinical experience, policy work, and research to discuss why perinatal-specific approaches are needed, the prevalence and impact of perinatal mental health difficulties, and how therapists can adapt CBT to meet the needs of diverse parents and families. The conversation also covers access to care, the role of identity and stigma, supporting culturally diverse and neurodiverse parents, and therapist wellbeing when working in this emotionally heightened period. Whether you're working in NHS Talking Therapies, secondary or specialist care, private practice, or simply want to deepen your understanding of this vital area, this episode offers compassionate insights and practical strategies for helping parents during this transformative time. Resources & Further Learning: · Find out more about the Pearl Institute here · Access the Perinatal Positive Practice Guide here · Take part in the Jame Lind Alliance perinatal mental health survey here · Listen to the our previous episode on OCD in the perinatal period with Dr Fiona Challacombe Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT-Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, we have the pleasure of being joined by not one but two experts in perinatal mental health, Professor Heather O'Mahen and Sarah Healy. Professor O'Mahen is Professor of Perinatal and Clinical Psychology at the University of Exeter and world leading expert in treatments for depression and anxiety in the perinatal period. Her work focuses not only on improving treatments, but also on improving treatment access, for example, through digital delivery. Heather is also currently National Clinical Advisor to NHS England's Perinatal Mental Health Policy Team. And Dr. Healy is a leading perinatal clinical psychologist with over 20 years' experience in the field. She co-led with Heather the development of the Talking Therapies perinatal competency framework and contributes regularly to the development of perinatal mental health policy. They've also founded together the Pearl Institute, which provides evidence-based training for clinicians working in the perinatal period. You're both so welcome. Thank you so much for making time in your busy schedules to come on the podcast. I think the fact that from the first planning to recording this podcast has taken us about 10 months is probably a good indicator of just how busy you are doing this brilliant work. Heather: Thanks for having us, Rachel. Rachel: Now, I know you're both hugely committed to working in perinatal mental health, and I'm wondering how you came to work in the field and what's kept you fascinated by it personally and professionally? Heather? Heather: Well, I came to it accidentally. I applied to do a post-doc at the University of Michigan when I was living in the States and it was in primary care. But they had rejigged things and then said, we have this other one in perinatal mental health, would you be interested? I had a long-standing interest in women's mental health so that sounded really great to me and I said, yeah, I'm definitely interested. Then I started doing therapy with women, parents from the perinatal period, and also doing research in the area, and I just couldn't stop. It's such an incredible, transformative period in people's lives. It's such a meaningful time to get to work with folks. There's so much that's going on, but there's so many opportunities to walk alongside people during this period of change. And then of course I had my own children and that fed it further. And so here I am. Yeah, yeah, yeah. Then you learn like, wow, it really, really, really, really is important. Rachel: You learn what it's really about. Fantastic. And how about you, Sarah? Sarah: Yeah, I guess I came a bit of a roundabout way into perinatal. My early kind of career was more on the research side of things, but I started with a master's in the psychology of early development. I was really interested in that early mother-infant relationship. So I did my PhD in that area and I kind of been moving towards clinical psychology. Thought I would end up in CAMHS because I really liked working with children and that kind of parenting piece and then have the great fortune of having an assistant psychologist post in a mother and baby unit. And I just really found the work fascinating and as Heather kind of said, such a transformative time to be working with. So that kind of started me on my perinatal path. And since then, I've really just found the work so rewarding. And similarly having my own, my son, obviously now eight, he just turned eight. The perinatal period is a little bit a while ago, but I think I learned a lot from the work that really helped me as a parent and then being a parent really, I guess, added to my knowledge and passion for the area. Such an exciting, interesting area to work in and you get such variability in the type of difficulties people are having and the outcomes are so rewarding. I get emails from clients I saw years ago, of pictures of their children that are now eight, nine, ten, and you feel you've been really part of that process. Rachel: Wow. So it sounds like you both really have a deep commitment to women's mental health, to parents, to babies, to seeing kids develop and thrive. And that you've really enjoyed working in this joyous, but also incredibly vulnerable and challenging period with people where you can really make a difference. Now, certainly my experience, I've got three kids and experienced postnatal depression after two of them and I remember look back at it being such a precious, incredible time, really special time in my life despite that, but also all these challenges that are piling in. And yeah, at eight, the challenges continue don't they Sarah, but there's a little bit more sleep maybe. Sarah: The sleep is nice. Rachel: But it sounds like you also both had an excitement about bringing together research and practice around multiple areas like physical and mental health and adult and child developmental psychology in ways that can make a big difference and you both obviously live and breathe this work at home as well. But people who haven't worked extensively in the area might ask if we need a special approach to perinatal mental health, you know, can't we just apply what we already know about the evidence-based practice and approaches to depression and anxiety, for example, for the adult population and adapt those where we need them in line with our individual formulations. Heather: I think that's a really good point. And the evidence would suggest that we can adapt many of the interventions that we do have, but that it's really important to understand what's going on for perinatal parents during this period of their life and to be able to, in those formulations and in those adaptations, make sure that you're addressing the key issues that are important for them. I think this has been for some and maybe historically challenging to get their heads around maybe a little bit. Back in the day, back before there was this lovely investment in England in perinatal mental health care, it was certainly the case that I would talk to some clinicians or service leads and they go, ah, but we don't really see that many perinatal parents in our service. I don't think there's actually really much of a need- and nothing could be further from the truth. The need is just as great, if not greater and we know that we see an increased incidence around issues like say OCD during this time and also that there are real problems around birth trauma and issues around loss as well. So it is that parents do experience problems during this time. They do want support, but they want the support that's really family focused, that really understands that the baby is so integral in their lives at that point, and that can address it. And we can do that, but we need to get it right. And if we don't, we don't see the parents, just like the service leads said, we won't see them if we don't get them what they need and want. And I think we can compare this to other significant problems that people might be having and very intensive or transformative parts of their lives, like veterans, for example, or people with long-term medical conditions. And we definitely see the priority there that we need to adapt for those problems as well. So likewise let's do right by perinatal parents. Sarah: I think just to add to that Heather, I completely agree with all those points there, but also thinking about looking at services that are doing it well. And when you have services that really are adapting their interventions to be specific to clients in the perinatal period that are doing lots of outreach, that are liaising with other perinatal colleagues, other health professionals, they are getting the clients. They are seeing a lot more perinatal clients and they are getting the positive outcomes. And similarly, most of my clinical work now is in private practice and people are sometimes coming having had not so great experiences of much more generic interventions where they didn't feel people really understood what they were going through, weren't taking into consideration, say, preparing for birth or timings of interventions, didn't really understand the demands of having a small baby or some of the physical issues that might come up at that time. And so we're looking for something that really could take that consideration in time. And often that's the feedback I get as a clinician. It felt like you really understood my journey. You knew what was coming up for me or what may be challenging or difficult. You're really able to help me prepare or link in with other services. So I think the feedback both from clients and you know from services that are doing a really good job about being responsive to perinatal clients, and not just the birthing person, but to the wider family. The feedback is always really positive. Rachel: So we need this specific approach because there's something different about the context we need to take into account. There are specific issues that people are dealing with. And I'm really struck by what you say that if we get it right, people come. If we're not getting it right, we're not going to see these folk and you can draw that faulty conclusion that that's because we don't need it. But that probably applies across the board to lots of different diversity issues and specific issues at different times that people experience in life. And you mentioned, Heather, that there is an increased prevalence of some problems around this time. How significant a problem are the psychological disorders in the perinatal period? Heather: So overall, the problems in the perinatal period, and we've just got new data out on this. So the Mental Health Intelligence Network has worked with NHS England to produce new prevalence with regional data as well on perinatal mental health. So, we know that mental health problems are about 25.8 %, just about, have perinatal mental health problems. Outside of the perinatal mental health period, you're probably talking about a similar slightly lesser prevalence rate across all of the problems. But some of those differences that you're going to find are, say for example, in OCD where we do see a higher prevalence rate. And I think what's also really interesting is that if you ask women who have had OCD at any point in their life, when did it start? A significant number up to about 50 % of them will say during the perinatal period. And also we have sadly high rates of birth trauma and PTSD associated with difficult childbirth experiences. Rachel: And if listeners haven't heard it already, we did a great podcast with Fiona Challacombe who talked a lot about OCD in the perinatal period, which was really so informative and so helpful. So we can see that there are these particular issues which may be raised in this period, but you're all saying that there's also the case that there may be, it may be the genesis of some problems that continue for people much longer than that. And then we may see them later in their life, but this is the period where it perhaps if we got in there and nip things in the bud, we might be able to make a really significant difference over time. And thinking about trauma, which you've spoken about, I provide supervision to folk in Talking Therapies and other secondary mental health settings, delivering trauma focused cognitive therapy for PTSD. And I've noticed that there has been a huge number of cases of perinatal loss coming through. I know this is an area that often culturally wasn't spoken about in the past. What does the data tell us about the prevalence of perinatal loss and outcomes for women and their wider family? Sarah: Yeah, it's interesting. We've been doing a lot of training to kind of increase awareness of the impact of perinatal loss and the prevalence of perinatal loss. I know that it's unfortunately a very common phenomenon, one in five pregnancies will end in miscarriage. We also have to think about the prevalence of ectopic pregnancies, around one in 90 pregnancies, tradition of pregnancies, stillbirth, neonatal deaths, a lot of areas in which one can experience a perinatal loss and that we do know that that can have a significant impact on people's mental health and that's reflected in the research with higher rates of PTSD so the prevalence of the research in this area is growing, but there is some evidence that the incidence of PTSD is higher than what you would expect following say childbirth in the general population. So anywhere between 7 and 20 percent. And also we see higher incidences of anxiety and depression following perinatal loss. We really need to be able to think about how we're offering evidence-based treatments. It's lovely to hear that that's coming up in some of the trauma-focused CBT work because I think one of the things that when we're doing training, we have to talk about is, we need to make sure we're treating the right difficulty or problem. And sometimes when people come with a lot of distress, which is so understandable, following a perinatal loss. They can get immediately signposted to bereavement counselling and that type of support, which may be absolutely appropriate, but we don't want to miss the PTSD, OCD, anxiety or depression that we might need to be supporting with someone with following perinatal loss. So lovely to hear that that's being kind of brought up in your supervision and people are being supported with that. And I think it's one of those areas that actually you do need a little bit of perinatal specific kind of training or information that you really need to inform yourself, kind of what that might have been like for somebody, understanding the physical implications of some of those losses for someone that had to birth a baby or maybe may have been producing milk after birth and have the kind of physical recovery and all of those areas that could have been quite traumatic and might be part of what they're struggling with in the present or they may be struggling in a subsequent pregnancy or contemplating future pregnancies. So thinking about actually having a good grounding and understanding about the different implications of all these different types of losses and ongoing investigations that they might have to be kind of considering or thinking about implications for future pregnancies. So it's a really big area that it's lovely to see getting more attention. So I think this is an area that wasn't really thought about much historically. And anyone who's experienced any of these losses really knows from a very personal place, the kind of impact of it. And we really want to help people be able to kind of process and accept and understand that it's normal to be grieving in this period, but we need to also be addressing any mental health difficulties that might be there. Rachel: Yeah. So it's really good we're seeing these come through and hopefully rewarding for both of you as well, having led on the good practice guidelines, you know, to see people and services following that and picking up on these cases early on and intervening. And I guess that leads us to think about, you know, the access issue that people have. What are the challenges people face in accessing good support in this period of their lives? What makes getting support difficult if indeed it is so. Heather: So I think we have to recognize from the perspective of people who are seeking support, it can be challenging just in general. But I think during this period of life, when there's so much that's going on, so you start off in pregnancy and you've got a lot of appointments that you have to go to, a lot of people are still in work, or they have other children. And so they're juggling all of that and appointments. There can be stigma. We would like to think that we've gotten far with stigma. But there is still quite a lot of stigma that people feel and that can vary across different kind of cultural or economic backgrounds as well and people's willingness to talk about those problems. And sadly, although it is rarely, very rarely the case, but sadly, a lot of women will say that they fear that if they say anything about their mental health problems, that their child will be removed from their custody. And a mental health problem alone should never be the reason to remove a child from somebody's care. So all of these things can be barriers and then there's trying to get into the treatment. If you tell a healthcare professional that you have a problem, you hope that they hear you and that they recognize those problems and that they appropriately refer you on and you get a smooth transition into service. But we know that can sometimes have difficulties and challenges as well. It can be challenging in part because it is normal, say, for example, in pregnancy to have a slight increase in anxiety. And from a healthcare practitioner perspective, and we've seen this data in large scale epidemiological studies that we've analysed, from a healthcare practitioner's perspective, that could be, oh well, it's normal to be anxious during this time period. But it's not normal to have problems that are causing you a lot of distress, most of the days that are impairing on your functioning that are kind of taking over your life. And so it's really healthcare practitioners understanding the difference between what's a little increase in anxiety and what's not a normal experience for somebody and where they do need a bit of extra support and then getting onto that support. Rachel: And I'm hearing that there are these practical barriers, and it does feel like sometimes you're taking on another full-time job, doesn't it? When you get all these appointments through the door when you're pregnant and there can be our own psychological barriers to worrying about how that's going to be perceived. And we're changing our sense of identity of someone who's very career focused, potentially having this other pool in demand in our time and other focus on our energy. And there are also structural barriers you were saying around healthcare professionals recognizing what's going on. I remember myself being given a poorly photocopied depression self-report measure with some of the items cut off the bottom. And as a psychologist, of course, I was slightly horrified that they were going to be adding up these scores incorrectly and not knowing what they meant on the standardized test. I also remember feeling huge performance anxiety as a new mum, you know, every weigh in or extra hour of sleep or developmental milestone was a measure or felt like a measure of my success or failure as a human being, or as a mum and a real need to appear to be, and also to be on top of it all. So, you know, it sounds like there is still a stigma that people experience of feeling like they don't want to admit to their mental health symptoms. Sarah: And I think Rachel, thank you for sharing your experience. I'm really sorry you kind of have that experience of someone actually not really talking to you about it, giving you a fuzzy measure to fill out that wasn't even probably an appropriate one if things were chopped off a bit. But I think unfortunately this is the experience that people sometimes have in the perinatal period. And it's definitely when I've heard clinically upsetting amount of times really is you know it takes so much to go and say I'm struggling; I'm finding this very difficult. Everyone keeps saying I should be excited about the pregnancy, or I should be enjoying my baby and I'm really not. And so to then come and ask for help and have that dismissed or not taken seriously or just offer, quite a few people I've heard just offered medication and they don't for various reasons don't want to or they do but it's not helping and not talked, they're not being talked to about what their options are in terms of talking therapy or support and making those referrals as easy as possible, not giving someone another piece of paper to go away and then they've got to kind of contact someone and fill something out and then they say we're not the appropriate service and you get bounced to someone else and unfortunately, you know, I've heard a lot of times where people are having to go multiple times to say I'm really scared about birth and they're not getting referred till they're 30 weeks pregnant and that you're limited in terms of what you can do clinically where somebody's been saying that right from the get-go at their booking appointment. So I think, you know, really healthcare practitioners need to be picking up on this as early as possible and if someone's asking for help, making sure that they get it. Rachel: And I guess if there were some barriers or issues for me as a white middle-class educated psychologist in this country, that might be even more significant or there may be challenges for people in other social and cultural groups. What do we know about that, about barriers for other folks? Heather: Yep, you've nailed it, Rachel. It's not an easy system to navigate with all the privileges. If you don't have a sense that this system is going to work for you, if you have a sense that maybe the system could be even discriminating against you, and certain groups have those experiences. So it's very difficult to trust a system that may be the very system that's hurt you and to get into treatment that way, or also to trust that this is the right place for you and this is what you would want. And even if you do trust the system, you've got to keep persisting often. And there's sometimes, I think, a sense that certain groups of individuals can have that we deserve this, we should keep going at it. But that's really hard work if that's not the mind frame that you're coming in at it with. What we do see, and we saw an evaluation that we did in the ESME 2 study, is that very frequently it was grandmothers who came in and they said, it's unacceptable that my child, my daughter, who's now a mother, is suffering like this. And they were the ones who persisted in the system. But if you don't have that support, how are you going to get in? And I think that's something that as clinicians, we can increase our awareness of that and think about how we can do outreach. We can't just sit back and let people come to us. We have to reach out to them as well. Rachel: And what are the outcomes for people from ethnically and culturally diverse backgrounds like at the moment? What do we see in terms of their journey through this period? Heather: Right, so the good news is if they do make it into services, the evidence that's coming out, particularly evidence around the new perinatally adapted services, is that it's good, it's positive. We also know from the Rushney 2 trial, which is an amazing large-scale study with South Asian women that adapt the interventions to what people need for their cultural needs as well, they will show up and they will do brilliantly. So the good news is, to repeat this theme again, if we provide the right kind of adapted interventions, they're acceptable and people have good outcomes. But if we don't, it's a real barrier and they don't get the same access to treatment. So we see that time and again, both for ethnically diverse groups and that's particularly acute for women from Black and Afro-Caribbean cultures, but also for South Asian cultures. So they don't tend to get access into it. And we also see this for people from lower economic situations, particularly the lowest economic strata. And often those are the individuals, they have so many stressors that they're dealing with, economic stressors as well and they may not have the transportation and the resources and the childcare to get into interventions. And they are more at risk for mental health problems. So we should be seeing more of them, not less. Rachel: And you mentioned earlier that one of the factors in stigma can be people are worried about their kids being taken away from them. They can be worried about how they're being judged. Is that a factor that's heightened for people from culturally diverse backgrounds as well? Sarah: Absolutely. I think, you know, people may have had experiences that have been quite negative with other health care professionals or other bodies like police or social care at different times and feel that they are more likely to be judged when they present with mental health difficulties and have more of, you know, you kind of were talking about Rachel, you're kind of, I'm a psychologist and admitting I was kind of struggling was tricky or difficult or felt challenging, you know, if you're carrying this weight of, I should be coping okay, people are going to judge me based on kind of my ethnic background, my socioeconomic status, they may be much less likely to disclose that they're having those difficulties and they have, you know, negative experiences where people are judging them. And definitely that's something we've heard kind of clinically where people are from in maternity when they're giving birth or the care they might receive at different times. There's a sense that I'm being judged, so not wanting to kind of come forward and ask for help because of that fear. Rachel: And do some of the same or different factors show up for same sex couples? Sarah: Absolutely, and I think this is an area that I've kind of really been looking into a lot more and we've been thinking a lot more about. I think even to the point that somebody presents to a talking therapy service and comes in and initially they're asked, what about dad? And there's an assumption made about the sexuality of their partner or that they have a partner. And I think male same-sex couples, there's very few services that actually they can access which is discriminatory really, you know, I think they can access talking therapy services but may meet a whole load of discriminatory attitudes or just even comments that they're not thinking about somebody's, you know, family background. So I think we always encourage people to talk about birthing person and partner, but also not making an assumption that there is a partner, you know of people having babies on their own and often by choice. So there's kind of a growing number of solo parents that are choosing to do this on their own and may feel an extra burden of asking for help because they've had a lot of effort into having this baby. So admitting that they're struggling or need some extra support might feel have an additional layer of shame attached to it that we need be sensitive to and talk sensitively about. So, you know, when we're meeting someone for the first time, not making assumptions about if they have a partner, who their partner is. Rachel: So we spoke a little bit about outcomes for people from ethnically diverse backgrounds that they can be good once they get into the system. Generally speaking, is CBT effective for depression and anxiety in this period? Is it as effective as it is in other periods of people's lives? Is it equally effective for everyone? Heather: So the evidence base in this area for CBT is for CBT that's been adapted. We haven't done studies that have looked at not adapted CBT. So we know that if you adapt CBT, you adapt it well, you're still doing good quality CBT, then we've just done a recent meta-analysis on this, it's just as effective as outside the perinatal period. So that's great. There's good hope for folks. Now that was for depression. We have less evidence base for anxiety, but some of the emerging studies suggest that there's promise there. But there's a significant research gap there and we really need to do that work. Rachel: So if we can get people in, if we can reach them where they're at, and if we can adapt the therapy, there's good hope there that we can be useful and helpful to people. And let's think about those adaptions then, and there's augmentations that we might need to do. What perinatal specific input is important to include? And I know you've talked about a few of these aspects, but putting it together, what do we need to really make sure as part of that package? Sarah: I think we really need to understand the perinatal journey. I think, you know, knowing what the different appointments someone might have, what the different kind of physical health implications might be to pregnancy, what timing points you need to think about. So, you know, for example, if someone refers in hopefully, you know, 14 weeks, write down the date that they're due so you can be planning and thinking about that as you move closer to that time and you're starting to think about birth and preparing them for what they might need to think about around that. So understanding different birth options and choices and where they might be seeing healthcare professionals that you might need to be thinking about managing, if they get really anxious before medical appointments, which ones do you need to know about? So really thinking about the journey and the postnatal journey thinking about, you know, people often forget things like when babies start to wean at that kind of six-month point, that might be a real increase in anxiety for some people. Say you're working with someone with contamination OCD, kind of starting to their baby is going to be something you're really going to need to think about. So knowing when that happens is really important. When people are going back to work, for example, after maternity leave and having to leave their baby in nursery, which I'm sure for all of us is so challenging and difficult. And for someone that might be really anxious or feeling really low or they're not doing good enough, leaving the baby in someone else's care might be really anxiety provoking. So really understanding and be able to think with our clients about that journey. The other area I think is really important to think about is family picture. Thinking about the baby, the implications of the baby, involving the baby in treatment, seeing the baby wherever we can working with baby in the room and also partners. I'm trying to think of cases where I don't bring the partner in the room because most of the time, at least for one session, I'm going to involve the partner or sometimes as you said, it's grandma, the client's mum or sister, whether you're working with depression or anxiety or OCD, I think I find it hard to think about doing OCD work without bringing in somebody else there to really help kind of think about extending the work outside of your therapy practice. So really thinking about the perinatal period is not just the person, you know, that might be birthing the baby, but the wider system and involving them where we can. The other one is about risk, know, really understanding the nature of perinatal risk. What are the real red flags you need to watch out for or think about and understanding certain presentations like if somebody has a history of postpartum psychosis themselves or their female family members or Bipolar I, you know, they should be even if they are well, they should be under the care of specialist services so that we can really plan and think about reducing risk of relapse and things like that. So really understanding the awareness of risk, thinking about liaising with other professionals. So you need to know who's in the system and understand the perinatal system. So knowing that people are going to come across midwives, health visitors, obstetricians, their GP, children's centres, knowing what's available in your area, you know, if you're doing, and that might be as simple as, you know, you're doing behavioural activation in the postnatal period, knowing what baby groups are available, and depending on the client, my personal favourite was baby cinema. Cause I could just sit there and relax. I'd like, so knowing, you know, kind of these sort of things are not, someone might not feel comfortable going into a baby group right away. That might not be a good first step, but you might be able to convince them to do baby cinema or, you know, what are these first steps? But you kind of need to know the system around. Rachel: What I needed my healthcare professional to know is exactly which groups were on at exactly the time my children weren't napping, which is probably an insight to the rigidity of my parenting style more than an issue with the system. Sarah: It reminds me of another really good point there Rachel, in that the napping is like we need to be flexible with our timings of appointments because you know babies needs change and somebody might want to bring the baby to sessions but they might also want to do them when baby's sleeping so being able to be flexible in that way so you know your appointment time might change as baby grows or pregnancy to postnatally and it's definitely the case you know in my work sometimes in pregnancy I might be seeing someone outside of working hours and then that really change postnatally and I might be seeing them first thing in morning when the baby's having the morning nap. Rachel: Which is the joy of parenting, isn't it? Just when you think you've got it nailed, it all changes. Sarah: Absolutely, that need to be flexible and understand all those different stages, know, what we would expect and even in things like baby movements in pregnancy, it's often a real trigger for anxiety, is my baby moving enough? So having a good understanding of what we would expect at different stages so that if someone is really anxious, we're really coming from an informed position to help them think about, say reducing checking or things like that but also being able to liaise with midwifery to get a good sense of what's going on for this individual client there on their journey. Heather: Sarah, I think all of that is just really gold. And I think as you were talking through it, I think it paints a beautiful picture of how integrated the baby is to every single experience for the parent and how much you need to take account of that. And I suppose this is a BABCP podcast. And so there might be Talking Therapies folks who are listening and so there's so much I think in Talking Therapies, which is very adult focused that you can do while still thinking about the baby. And I think one of the key things is for all people working in this period is really understanding as well the impact of mental health problems in the parent on the baby. So this can be a tricky, a little bit of a minefield for some folks. There's this idea that if you are a parent and you have a mental health problem, then boy, your kiddo is terribly at risk. They're going to end up with all sorts of problems and that's the way that it is. The good news from the longitudinal data is that although there is an increased risk of that, it is just that it's a risk. It's definitely not a given. There are lots of parents who have mental health problems during the perinatal period whose children end up being just fine. And so, it's not written in stone and there are actually lots of things that you can do and taking care of yourself as a parent is an important first step and an important lesson for the child as well. It's good for kiddos to see that their parents can take care of themselves and to model that throughout their entire lifespan. That helps to build healthy children as well. Rachel: That's such a hopeful message, as well as kind of feeling and experiencing the misery of depression or anxiety in that period, then to feel miserable that you're also damaging your child's prospects, can only just deepen that experience, can't it? Heather: Yeah, yeah. And I think from a clinician's perspective as well, they can watch the client who might be with a baby and working really hard and doing a very good job with that baby. But they might also report that they don't feel so close. They don't feel that rush of love. They don't feel that bond. And those are two different kinds of things. So addressing both things for the parent and helping them with the compassion towards themselves as a parent as they build that bond. It's a process often building that bond and it's hard to do when things are really rubbish. But at the same time, they might be parenting really well. Sarah: Absolutely. you know, Heather, as you were talking, I was also thinking, you know, we're talking about adaptations to CBT and things, bringing in that perinatal expertise, understanding the journey. But also, we're not talking about avoiding doing evidence-based work. You know, the adaptations is bringing in that knowledge, bringing in that experience, bringing in those other professionals and the wider family and the baby. But unfortunately, you know, Heather and I bang on about this, because every time we do training, somebody will bring up that their supervisor, either current or historical, said they can't do exposure-based work in pregnancy. This is just not true. So, you know, it's really shocking to me to hear that we are discriminating against pregnant women who aren't getting the treatment they should be getting in terms of EMDR, trauma-focused CBT, exposure-based work around panic or OCD and thinking, oh we'll deal with that when the baby comes. And so somebody is sitting through pregnancy with all these kind of symptoms and distress when they're coming to serve as wanting help. And then we're not kind of helping them before baby arrives, because that's not going to get easier. So I think we really also want to encourage people to use what they have and to use that evidence base to offer good treatment to clients in the perinatal period. Rachel: I think it's so helpful for clinicians to hear that really clear message that this is not contraindicated in pregnancy and beyond because people are worried about doing harm, aren't they? And they really want to do their best by their patients. But as you say, withholding the very thing that's going to help them is not doing your best by people, but it's understandable that people have those fears and absence of that knowledge. So grounding this little practically, if a person presents for support with, for example, depression or panic disorder or PTSD, aside from the psychoeducation around the perinatal period that you might want to be aware of and include and thinking about the wider system in your formulation and drawing on social support. Are the interventions we do essentially the same evidence-based approaches as one might usually take to depression or panic or PTSD, or is there something fundamentally different we're doing? Heather: So the good news is no, you're not. If you're doing CBT, are you going to continue to do say cognitive restructuring and behavioural experiments for depression? Are you going to apply behavioural activation for depression? Yes. You're still going to do the same principles. If you're doing PTSD treatment, are you still going to do imagery work? Are you still going to do, you know, narrative work? Yes, you are still going to do those things. But it's about taking all of the information that you have about the perineal period and thinking about how, what you are applying that to and how you are applying that. So for example, if you're trying to do some behavioural work for depression, what is it like trying to do that when you have a baby. What's going on? What are the things that have gotten this person separated from meaningful activities that bring them joy and valued based work into their lives? And so very frequently it means that you have to rejig kind of the what they got more broadly from what they were doing before they had this baby into these activities with this baby who doesn't give any clear reinforcement signals back. So that's the challenge. And it can be a bit tricky. Or if you're doing PTSD work and you're trying to do some exposure work, it's understanding, for example, that maybe if somebody's had a traumatic childbirth, and they have extremely vivid images of perhaps either the thought that their child was going to die and or that they might be dying, how important it is to do that imagery based work and how important it could be to involve healthcare workers alongside to help to support that work and to help to support maybe even getting back into a maternity based setting and to be visiting that place. It's about really understanding the beliefs that were going on for them. For example, that nobody's helping me during this period. Nobody is caring about me. Nobody's going to help me. And how deeply that can touch on some really embedded kind of beliefs about themselves. So it's still doing the work that we know what we need to do, but it's really zeroing in on what is going to be the most harmful thing right now and going after that. If you're trying to, for example, go for a traumatic childbirth experience, it's also understanding that they may have had experiences, medical health experiences during that time that are medications that are contributing to loss of memory. And how is that going to impact on the ability to process that trauma? Sarah: Yeah, I would really echo what you've said there, Heather, you know, that sense of it's not you're still doing the work. You're still doing a lot of the same things you would do. So with OCD, for example, you're still doing experiments. You're, you know, getting out there. You know, you might be, you know, either I have people like put me on their phone and we're going for a walk or going out. You know, you can be really creative about how you get out there and active with clients even in a remote setting. But I think there's also the timing and planning issue, know, thinking about when they're referred, thinking about birth and some of these things that might be coming up and kind of having that knowledge. So I think you know what we're talking about a lot is really having a good deep grounding or understanding in the perinatal period. And if you don't know, ask your client, you know, what's coming up for you, learning from them about, you know, what they might be anxious or worried about and making sure we're asking the right questions. You know, in assessment, are we asking, you know, how many times, you how many pregnancies have you had, not just how many children do you have? So we get a sense, is there some loss in the background that might have led up to this? How was your journey to getting pregnant? You know, has somebody been through a lot of fertility treatments? And I think that infertility and fertility journey is one that often isn't really thought about and has big implications for when it's meant to well-being. So knowing to ask these questions and knowing when to normalize and kind of really go, oh man, it is so tough, you the lack of sleep and when it's like, actually this feels like you're really struggling, we really need to think about kind of intervening here. So you know, being able to make those judgment calls on what's kind of typical and you know, really understandable in those early days and what's a sign that someone is really, really struggling. And that kind of expertise or knowledge is really important and helpful to kind of hold in mind. I could keep going, Rachel, because there's lots of other bits, you know? I haven't even mentioned NICU, you know, people that have babies that have had experience in neonatal intensive care and, you know, where parents are told to like intensively monitor their babies breathing and symptoms. And then how do you let go of that as your baby grows a bit? So, you know, we need to understand what that might have been like for someone having to make continuous decisions about their baby's medical care. You know, what having to make choices, avenues to pursue or not pursue and having to ongoing kind of health implications or not knowing what their child's development is going to look like. You know, so all these different areas that yes, you might be doing the same thing in terms of the kind of good grounded CBT or EMDR or whatever your approach is. But you're still going to do that, but you need that knowledge and expertise around what someone's been through so that you can ask the right questions. People know, and it's okay to not know and say, I'm not really familiar with that fertility treatment, can you tell me a little bit about it? What did that involve? How was it for you? You know to really be making sure you have a good picture of what's actually going on for someone. Heather: One last thing that I wanted to say is although almost everything that we're doing is the same kind of the same principles, approaches in CBT, I think one thing that we can slightly adapt a bit is around how we're dealing with challenges around getting support. There are a few times in life where you need as much support from a broader network. This is definitely one of them. And for a lot of people, that's really difficult. There's so much that's going on and then there's this big ask that you need to go out and get more support from people. And that is really, really difficult. So kind of the approaches that people have used in the past that just got them by just barely, it's not cutting it anymore. So things like communication strategies are really important here. Now in CBT, we have some nice assertiveness skills, but there's a lot of shoulds in the perinatal period already. There's so many shoulds. Do we really want to add like, you should communicate like this? So I think there's adaptations around thinking about what kind of communication is going to work for you in different kinds of situations. And it's okay if it works for you and it's working for the other person as well that's fine. So I think there's a bit more about really understanding and mapping people's social support networks, helping them to develop that support, helping them to get the support that they need and to communicate that support. And then I also think there's a bit around folks' social anxiety rearing its head a bit, and we don't talk that much about that during the perinatal period. But it's huge, I think all of us who work in the perinatal period see that all of a sudden, you're supposed to be talking to all these healthcare providers, you're supposed to go to baby groups, what? And then you're going to end up at the school gates down the road as well. And so for somebody with social anxiety, that is massive. And as CBT therapists, we have a lot of skills that we can apply to that. So I think it's keeping that in mind as well and thinking that might be a barrier for lot of things that parents need to get to and how can we creatively think about how to address those things during this period. So it's an opportunity to redress social anxiety, things that people might have let quiet their lives and are rearing their head again. Rachel: I love that positive reframe Heather as an opportunity to address these issues. And I guess what I'm hearing is that in an ideal world, we are really well informed as therapists. We understand this perinatal period. We understand all those issues from the normal journeys that people might go through, normal in inverted commas to, because everyone's journey is different, right? But there may have had issues around neonatal care to those people that might have differing issues around their context and the support that they have, or they don't have, I love this idea of this fearsome grandmother who might be advocating on your behalf, but not everyone has one of those, right? But also, that core skill in CBT of remaining curious and collaborative with our clients is really important and can get us a long way. We probably need to know a bit more than just what we can ask because sometimes we don't know the questions to ask if we don't know a bit about the context. And so that training and understanding is really important, but not to be paralyzed when we don't know either to be remain curious and remain in a place where we can sit with our clients and understand their context from their perspective and what they've been through. Heather: That's such an important point, Rachel, because I think that brings up a point about our own experiences or our own knowledge. And so some of us may choose to become parents and those of us who choose to become parents who are lucky enough to become parents, that's great. But then we bring all of our own experiences to that. And so it's about understanding that that's your own experience but also allowing for curiosity and flexibility around what this person's experiences are and not interacting too much of that. Rachel: And you've mentioned that various points when we've been talking different adaptions that might be necessary to allow people to access care. And I know that you're both very much interested and focused on improving that access in this period. What seems to work to help improve access to perinatal treatment? Heather: Flexibility. Trickier, I think for some services given some structures of services than others. But to the extent that you can have flexibility, I think that's so important. And so that can be flexibility, as Sarah was saying earlier, around different appointment times and understanding that, or around cancellation and DNA strategies as well. But it's also flexibility around where and how you are conducting these appointments. So it might be that at some point somebody prefers to meet in person and it's where they might prefer to meet in person, maybe in clinic, maybe they prefer to meet in the neighbourhood centre, in the children's centre. At other points it might be better for them to meet online, and they might prefer that. Some people might prefer always to meet one way versus the other, but to just be flexible to that approach is so important. Sarah: The other thing I kind of always, when I'm first meeting with someone, is encourage people to, it's okay if you need to feed, you need to take a break, you need to put the baby down or play with baby for a minute. So you might need to even have a little bit of a longer or sometimes shorter appointment time to allow for some of that flexibility. But giving that message from the get-go you know, whatever you need to do if someone wants to be in a session or wants a privacy to do that or wants to do it just after or before the session. So checking in with them about what's going to be helpful for you, what's going to make this easier for you. I think this is really key. Heather: And on that note, if you're going to see somebody in person, you need like a nice, baby-friendly, safe for a little crawling about six-month-old baby to be in the office with you or wherever you are seeing them. Sarah: That made me think of a couple other practical ones is like, you know, in services, making sure there's somewhere to park a buggy that someone's not trying to get a buggy up loads of stairs and things like that. There's a changing table. You don't have a changing table in your, in the toilets, you know, have that you can pull out. So if people need to change babies, you can do that. And the other that all of us will, you know, resonate with who have had small babies is reminders of appointments because, you don't know what day of week it is sometimes. So, you know, I think often when people have not shown up, it's not the same necessarily as when you might be working with clients in different periods of their life that, you know, often a client would go, my God, I'm so sorry. I totally forgot I've run our appointment today. But, you know, I send texts like two or three days before the appointment so people really can have that very fresh in their mind that appointment is coming because it's hard to hold information in and you have so many appointments for babies or pregnancy. Rachel: And if you haven't slept in five days, it all feels like one long day, doesn't it? Right? It's still Monday. Monday has gone on forever. I love these very practical ideas for services. It makes me wonder what other barrier services face in implementing these kind of adaptions. I can imagine even just being flexible over parent schedules and perinatal appointments can be a challenge for some services when they're used to kind of organizing around that hour a week at a set time sort of model. And I know from working in other areas, even to get a double session sometimes to go out and do a bit of exposure work when you're not thinking about all these added factors can be a challenge for services. What works and what services, what have services been able to put in place that makes that possible? Heather: So some services I know have put into place if they've got, say perinatal champions, they've got specific caseloads for those folks, and there's maybe just a little bit more space around it. So it allows them a little bit more space to do some more outreach to folks, maybe to juggle clients a little bit more flexibly from week to week. So that can just make a huge difference. Now, obviously, it's an ask. And you've got to provide a little bit of protection around that space in order to do it. Another thing I think that's just really practical that works really well when services do this is when they base their clinicians part of the time in another service. It might be in maternity. We've got one service in Somerset, for example. I'll give them a bit of a shout out that they have somebody in the neonate unit. And it works beautifully for that because they get to know people in the neonate unit and they can continue to see them after they've been discharged which is really nice. Or sometimes in children's centres as well where there might be a creche that's available. If there is, that's really beautiful, but otherwise there's nice child-friendly spaces. And they can maybe see them right when they're coming in for an appointment. So those things work really well. Sarah: I think to add to that, it's really nice for clients that they can come and see you in settings they might be already going into. It's also really good for clinicians because you're working alongside other professionals. So you develop those links very naturally. They know about you. You get a better understanding of what's available and what different services you might want to link your client into. And if you have a medical question and you're based in antenatal and you get to know the midwives, you can kind of go, can I just pick your brain? My clients really worried about this around birth. Is that something that's very likely? Is there anything, you know, you can tell me or help me in terms of supporting my client around this? So you're also developing those links in a really nice way. The other thing I was thinking about that works really well is, you know, and some services are doing amazing jobs of this is doing groups or services that are embedded within the community, so that are led by community groups that are already existing and particularly helpful for harder to reach groups or groups that may be really underrepresented. So working with community leaders, community organizations, religious groups, and in perinatal specialist teams, a lot of times as well, there's now peer support roles that also can be really helpful for increasing engagement and helping people come into the service. Rachel: So there's a lot that can be done and it sounds like a lot of this could be quite time consuming, quite intensive work, could be quite demanding of the clinicians in the system. And clearly there is a moral and ethical imperative to do this work, but you know, channelling for the moment, the mentality of a sort of hard nose number cruncher in the NHS (if these exist) in our leadership. Is there evidence that it's worth making these adaptions from the point of view of helping people access care and outcomes? Heather: Yeah, so let's talk about outcomes and measurable outcomes. Some of it is access, but some of it also, if we're going to talk about NHS Talking Therapies, you're also looking at the number of people who are adherent with treatment or drop out of treatment. So this is a great way to improve those numbers. And sometimes you don't have to apply the whole package to everybody. Some people need just a bit, some people need more, and it can make a real difference to those kind of numbers as well. I think as Sarah was really nicely pointing out too, if you're working really closely in some of these settings, let's face folks with healthcare providers, you can see that there's efficiencies in that as well. Maybe somebody has of fear of childbirth and you want to work on the birth plan with them and you want a psychologically informed birth plan. What we hear about, lots of people might work with clinicians around that, but is it implemented then in maternity? Well, if you're working, if you're able to work closely with somebody, a healthcare professional around that, then they're more likely to implement those and that person is more likely to have a positive birth experience. That's a positive outcome clinically. So from services, it makes a real difference to a lot of the markers that they are interested in. Then there's the broader kind of why are we doing this work and what are the drivers? And so, part of that is helping people to get well and the belief around that is if parents are well, there's a better chance that their children are going to do well. So we are making an impact not just for one person, but for two. So it's the broader social gains that we have there as well. Rachel: And not even two, from what you've said in terms of the family system. And not one person at one time point, but that person may be at multiple time points at the things that won't, they won't need to present for help with later on in their journey. Heather: Yeah, Rachel, I think that's such an important point because there's nothing more heartbreaking to see a parent who finally gets into treatment kind of with their second child or their third child and they talk about the heartbreaking experience that they had with their first or their second child and how that's impacted them with subsequent children later on or a parent who is later down the journey with that child and real challenges have emerged in that relationship. And that's just, it's a tragedy. It doesn't have to happen that way. Sarah: And I also think your point, Rachel, about the wider system. Any of us who have had someone close to us that struggled in the perinatal period, there is a real obvious ripple effect to that. Their partner seeing their partner in such distress or having such a difficult time is going to have an impact on them and their mental well-being. The grandparent's kind of seeing their child really struggling in this way we're helping a lot of a wider system if we're helping somebody who's struggling in that perinatal time point. Rachel: So not just the moral and ethical case for this work, but also it helps and it's effective and it helps so many people through intervening at these time points. Thinking about other adaptions, are there specific adaptions you might make for neurodiverse parents? Heather: I'm so glad that you bring this up, Rachel. So I have the great pleasure of getting to work with Verity Westgate, who is currently doing, she has lived experience of autism in the perinatal period and is doing her PhD on this right now. So what she's been finding in her research has been really great, I think. So first off, I think it's understanding, for example, autism and the experiences that an autistic parent might have. So considering that they might have sensitivity to sensations and what that might be like physically when they're pregnant, a baby moving all the time, the discomfort in your body, what if you're very sensitive? It's going to really heighten that. During childbirth, all of those noises and sounds and the pain, what would that be like? Likewise, once baby is born and now you're talking about routines and you're talking about crying and you're talking about possibly breastfeeding and all of these things are full or just having a baby on you. All of those things are full of sensations. It's thinking about with parents very practically about what they might do to manage some of those sensations so it's not tipping them over the edge. But it's also about a recognition that inevitably there will be a lot of sensations and smells and noises, et cetera, and they might need time to go and decompress and let some of that go. And it's really understanding the thresholds of where autistic parents, for example, might be versus non-autistic parents. What she has found a lot of autistic folks have said has been really helpful is a very practical and applied approach in perinatal teams where they've got an occupational therapy, for example, fantastic, it's been really positive. But I think within NHS Talking Therapies as well, there's a lot of practical work that we do. And so nice to know that, if we're thinking like, oh, to what extent does CBT apply to people with autism? Well, behavioural approaches work really well. It's really effective, you can get your head around it, particularly in the sleep deprived period, it can be really nice. So thinking about some of those adaptations. Also just thinking about routines, like autistic parents can be such great parents because they are good at routines, but baby schedules change all the time. There's a lot of flexibility that's also needed in those routines. So it's maybe not so much about getting into routines but thinking about how to flex around those routines. And then there might be a bit of communication work as well, thinking about the specific communication needs of those individuals and how they might want to adapt it during this period. Likewise, if you have somebody with ADHD, you know, routines and schedules, that might be a different kind of challenge and reminders and just thinking about what kind of cues you can use during this period with the baby when, woo, paying attention in the best of times is difficult, much less when you have a baby or if you're a hyperactive person and you're supposed to sit on the sofa with your baby and feed your baby a lot, like that is very difficult. So thinking about some of those things. Rachel: Well, as you're talking, I'm thinking of just what a challenge many of the things you're mentioning were like without that added challenge of neurodiversity or the issues that can bring with it. You know, the idea of finding decompression time when I couldn't go to the toilet for months on end on my own, you know, it sounds like there might be a lot of problem solving to be done around these issues or, know, the kind of issues around feeling like, you know, you just got a routine set down, it's working for you and then everything changes. All these things can be challenging for anyone, but if those are particularly challenging for you as an individual, then it must be so great to have support from someone who can work through that with you. Sarah: Yeah, and I think Verity's work is so interesting and really bringing a lot to our understanding of working with neurodiverse parents. And I guess holding in mind that that's not a homogenous group, that, you know, different people are going to have different things that help them or that they struggle with. you know, in the therapy context, you know, asking them what helps them to, you know, manage sensory stimulation or helps them with attention or what kind of things do they need to build some flexibility that might be helpful for them or where can they plan a little routine that might make things a little bit easier, both in a therapy context, like what do you need to do in sessions to help that person engage and help that person get the most they can out of therapy and in the parenting context and those two often align. Heather: And I think that that's so true and also want to highlight that actually a lot of people come into the perinatal period didn't know necessarily that they were autistic or had ADHD. And we know that getting that diagnosis, there's a huge wait list around that. It could be if you're in the NHS, could take quite a while for that. Rachel: It's not going to be nine months. Heather: It's not going to nine months. Yeah. So I think there's a both end. It's really important for clinicians, and it's great that this is rolling out more and more across the NHS and for a broader range of clinicians. It's really important to know about autism and about ADHD. so you have some of that knowledge so you can talk to parents who this might be a very different and new experience for them and think about what they might need in that context as well. Rachel: I feel another podcast coming on now and we will be doing that down the line. So you guys are obviously world experts in this stuff. You're used to doing it. A lot of this is going to be second nature to you, but in your years of teaching, supervising and applying this therapy, where do you find most therapists get stuck? What are the most frequently asked questions or the tricky issues that come up for you? Sarah: I think the most common thing is what we were talking about earlier, and I laugh because it does come up so much, but exposure-based work. People are nervous of doing OCD experiments in pregnancy. For example, what if they do have a miscarriage? Say the client's like, I wear this colour, I'm going to have a miscarriage. Or if I don't do my rituals in this way, then I'm putting my baby at risk. And so the clinicians are, what if they did have a miscarriage or what if that does happen? So their own fears are kind of maybe getting in the way of them doing that work. So really being able to talk through that in supervision and think about what you're trying to do and really remember that you're trying to help this person reduce their distress. And so increasing some anxiety in the short term is going to really help them in the long term, being able to cope with that baby when they arrive. So I think that sense of a therapist anxiety about doing the exposure-based work. I think, Heather and I, that's kind of the thing we probably talk about the most in a lot of the training, how to do that, what the evidence and research say, and kind of how to work through your own possible anxiety around doing that work. The other, the two other areas that I kind of come up with a lot, one is around loss, you mentioned, and some of the overwhelming emotion that people might be really understandably experiencing in that time and as therapists how we can be with that and sit with that and be that space where someone can talk to about how they're feeling around that. So I think managing big emotions not just around actually as I say it out loud and that comes up in lots of different contexts but being able to help people think about what's going on for them emotionally and make sense of that. And again, this might've been something they may be always struggled with, but they never were in a situation that was bringing up so much emotion for them. They're really struggling to contain or manage that. So that whole kind of area around managing emotions. And then the other one is around couples and the couple relationship that comes up a lot, I think. Either there, you might be working with someone individually and kind of, you know, according to what you're doing, you're like, why is this not working? They, you know, we're really. They're engaged at the work, they're doing the treatment, they're doing homework in between, but every week they're coming back and talking about their relationship. I think we underestimate how much support people might need in the couple dynamic in the perinatal period. And we know that that's a really challenging time for couples and relationships. And so sometimes the support that might be most useful might be couples work. I know a lot of talking therapy services, offer behavioural couples therapy. And, you know, I've often been doing training and I kind of said, no, just like put up your hands if you offer BCT in your service. And like most people put up their hands and then I say, well, now put up your hands if you think about using that with perinatal clients. And like, for some reason, like lots of people don't think about doing it. And I find it a really meaningful time to work with couples. They're really committed to it doing things different, changing the way they're communicating. But also, there's a huge amount of need to be talking a lot more, to be checking things out with each other, to be deciding on parenting and that kind of thing. So what kind of parents they want to be. So addressing those kind of couple relationships and dynamics is so important in the perinatal period. Rachel: When you were talking, Sarah, about sitting with those big emotions and managing what comes up for the therapist there, facing those huge issues of loss, for example, it really sort of makes me think about the emotional burden that we often hold as therapists willingly because we love doing this work and it's part of why we do the work. And I'm wondering how we look after ourselves as therapists when we're doing this work? Sarah: I'm so glad you asked that Rachel. I think this comes up so much and I think any training that I do, I embed this throughout because any time you're working in the perinatal period the personal and professional often overlap here and it's really important to think about it. I have to call it being perinatal in the perinatal period, doing perinatal work while you yourself are somewhere on your journey which might be you've decided not to have children. It might be you're thinking you might want to have them in the future. It might be, as you said, you've kind of experienced your own losses or you're pregnant yourself and how you kind of bring that into your work. Even I remember being pregnant and I was working in a community, a perinatal team, and even disclosing that you're pregnant, you know, when it becomes very obvious, of course, at a certain point. So, you know, with some clients, it was a real issue that I really needed to think about because they were really struggling or ambivalent in their own pregnancy. So a lot of times where you're actually having to disclose personal information in a way that is not necessarily typical of what we would have to do with other kind of with other clients or other client groups. So I think good supervision, first of all, is so important and having services that really understand and can think with clinicians about how you manage some of this and how you kind of, you might disclose things, know, thinking a little bit about those trickier conversations, but also thinking about timings of when you do certain client work. I think sometimes when I'm working with a client that may be there is a lot of emotion around baby loss. I might give myself a break after that session. take a little walk, get a breather, you know, be able to be present then for clients I'm seeing later in the day. The other thing is there may be times where you might need to think about changing your caseload. You know, I think even thinking about if you're working in a talking therapy service and you're you've had a miscarriage, it might be thinking with your supervisor about actually for a little bit of time, think these kind of cases are going to be too tricky for me and how you kind of can manage that. And some services will be able to do that. And other times, you know, the service demands might be different. But thinking about a lot of those issues and having space. And for me, I think also having really good colleagues. One of the things I love about perinatal work is the perinatal community, you know, and I've got some good friends working in this field as well. So being able to reach out to someone and go, oh man, this case is really tricky for me. I really just talk it through with someone else. Rachel: Yeah. And it sounds like you're challenging some of those beliefs we have often therapists, we should be on top of everything, or we should be able to handle every case or every issue that comes and actually that part of being good professionals is recognizing when this isn't the time for me or when I need a bit of extra support with this. One thing that's come through really strongly from both of you today is how important that message is that exposure therapy can and should be done during this period. I love the fact, Sarah, you went to the lengths of getting pregnant yourself to expose a client to other pregnant women. It just shows your commitment to the work. We also learn a lot from our clients, don't we? And I'm wondering what you've learned from the people you've worked with and how maybe doing this work has made a personal difference in your lives or the future focus of your work, you where it's taken you. Sarah: That's such a good question, Rachel. it's one I often, I often get asked, you know, did I change as a clinician when I had a baby? And like, is it, did being coming a parent make me a different, better, improved my clinical practice? And I say, it's the other way around. Actually, I got so much from the clinical work and from the wonderful clients I've worked with over the years that has made me a better parent and that helped me through that kind of perinatal period. And I think in a couple of ways, one in terms of tolerating uncertainty, you know, and that real awareness that we cannot predict a lot of what happens when you become pregnant, from when you become pregnant to what pregnancy symptoms you have, what your birth looks like, how feeding goes, you know, what those early few months are like, whether your baby sleeps well or doesn't sleep well. There's so much uncertainty. So I think I feel like because I've been working in perinatal, I went into becoming a parent with a little of expert knowledge and this is going to be a bit of a roller coaster, and I need to kind of flow with it. So that bit and then the other bit that I always kind of talk about what I've really has made a real personal difference to me is I remember saying to my husband just before we had our baby, nothing I say in the first six weeks counts. It's not an indication of how we're going to be as parents. I am going to sound crazy, I'm sure at times, or be short tempered or whatnot. I really feel like I should have said the first year, I'm really understanding that the perinatal period is a period of transformation and transition in relationships. I guess that might be your relationship with your partner, but even the wider system, your parents, your siblings, your friends. And kind of that awareness of actually, it'll always surprise you in some way, certain relationships that are either much stronger after having a baby or that can be really tricky or problematic and that you didn't quite expect it to unfold in that way. And I think those are the issues that my clients often bring. So I kind of stepped into it, I think, with an awareness. It still surprised me every now and then, obviously. Rachel: Anything you wanted to add Heather that you've learned from your patients in this work? Heather: Yeah, you know, I guess at any clinician working at any point, hopefully we're always learning from our clients, aren't we? So I feel like I've learned so much and it's been a bit of a gift because I would say all in all, almost all the parents that I work with, I'm so in admiration of them. They're trying so hard and being a parent is so meaningful, even when it's such a struggle for them. And inevitably, a lot of them think that they're just rubbish. I'm thinking, but you're doing such an incredible job. And so as a therapist, it's kind of a gift to say, right. Actually, we will have times as parents where we will just think this is not. It's all pear-shaped, it's not going the way that we want it to go. And actually, we're doing just fine. And I wish that every parent could have a therapist kind of perspective on things and to get to see that a bit and to help to grow that compassion within ourselves. Yeah, so thank you to all the clients that I've worked with. Rachel: That enable us to be good enough parents. Heather: Yeah, yeah, exactly, exactly. And you don't want to be perfect because that sets your kid up for failure doesn't it? Like they need to see that there's struggles and that there's ruptures and opportunities for repair. All of that. It's really excellent modelling. Rachel: I love that my kids are getting such a good model of an imperfect parent that that's really helping them. I also love this idea of space to explore and discover who you are as a parent, Sarah, that you said, know, this idea of the first six weeks or the first year being the safe space. We have a similar thing in our marriage. We had some very good advice from older married friends at one point that arguments in the car and the kitchen don't count. And I feel like it's a perinatal extension of that. There can be freedom and space to discover and learn and grow. And as Heather says, to be imperfect so that our kids can discover how to navigate the ups and downs of life through that as well. Rachel: So I know you're both really committed to your leading roles and promoting implementation of all of what we've talked about in services. Heather, what do you think are the key points around implementation that really need to be taken into account when we're thinking about this work in our services and our service systems? Heather: So we've been talking about how if you have great CBT skills, for example, that that's really important, but it's about combining those skills effectively and integrating your knowledge and skills within perinatal and working with the wider system with those existing CBT skills. So it's both, right? It's having great competencies in CBT and great perinatal competencies. So I think one thing that Sarah and I are very committed to is helping to support work both within the Pearl Institute and within the NHS and within private practice around ensuring that those competencies come together so we can provide the best care for people and for their border families. Rachel: So big question, what's happening for you guys? What are the big, exciting areas and how can people get involved in this work? Heather: So I think it's a really exciting time around perinatal mental health. It continues to be an exciting time. I think there's actually not just clinically there's been growth around providing perineal adapted provision, but also research has been growing alongside that as well. So first off, how can people get involved in research? There's a very concrete way they can be involved. There happens to be right now a James Lind Alliance perinatal mental health research prioritization exercise that is going on. That's a very long term that means people can have their say around what they think are the research priorities. So we are going to be launching a survey around this that will go out and anybody can respond to this. We'll also, we'll have a website on this, but it'll be on my webpage as well. So if people are interested to have their say, they can have a say. Rachel: And we can link to that on the show notes so people can click on that after listening to this podcast. Heather: Yeah, that would be fantastic. But there is just, there's a lot of work that's going on right now. Sarah and I are involved, I'm leading a trial, a multi-set trial for an intervention for antenatal anxiety. And we are following up one year postnatally as well. So we'll be looking at parent-infant outcomes also on that. And that one is...People are seen in NHS talking therapy. So we're recruiting them in scanning clinics when they're 12 weeks pregnant. And then they go on to NHS Talking Therapies and Sarah is our excellent clinical supervisor on that. I'm also involved in some research around early pregnancy loss with Camilla Rosen. There's just about to be a perinatally adapted DBT group trial that's getting started that I'm also involved in around that which is really fantastic. And then there's lots of work as well going on around understanding kind of the broader perspective of perinatal and who is getting treatment, who isn't getting treatment. So really looking at linked data that's in regular care and understanding that. So we're doing that here in England and we're also doing some of that work with Dharmintra Pasupathy at the University of Sydney. So lots of different things, lots of opportunities. It great also to start doing some more work around sleep in this period because at what other time are you more sleep deprived and the impact that that has on mental health as well. Sarah: Yeah, and I think so many, as Heather said, so many exciting things going on and we're kind of thinking about expanding the offer of kind of perinatal care. So thinking about how are we including partners more in the care and doing that couples piece of work but also thinking about working with perinatal law. So, you know, Heather and I both been involved in an expert reference group around adapting the prolonged grief treatment for working with perinatal loss with Kathy Scherr and colleagues in the States, which is really wonderful to see that kind of being applied in a perinatal setting. So really giving people some options of how to support clients who might be really struggling with perinatal loss. And I think, Heather and I are both really excited about the training piece, you know, that making sure that people are being trained in evidence-based treatments in the perinatal period. That was one of the things I guess we would have what I like to call our geeky chats, Heather. Heather would tell me about this neat research that she was doing, and I'd go, oh, that really applies to this client I'm working with. I might be able to kind of, I can really see how that would work here, or I might share that piece of research with them or I'd be talking about a client that I was kind of stuck with or something that, you know, it was coming up a lot and she'd be like, oh, I wonder, you know, that might really apply to this research. So we basically, that was the seeds of how we started the Pearl Institute of Perinatal Psychology and that we kind of thought, well, let's bring our geeky chats to a wider platform and bring in experts in the field. So I think we both get asked to do a lot of training. So we thought this would be a good opportunity to make sure we're offering people treatment that's really about how to adapt a lot of these questions have been talking about, how to adapt treatment in the perinatal period. So we've had kind of Fiona doing OCD and stuff around your childbirth. So I think I'm really excited about where that's going and what we kind of what experts were bringing in to do that. Rachel: Oh, there's so much going on, isn't there? It sounds like such an exciting field to be part of. And we will put all those links to the Pearl Institute, et cetera, on the show page for people, the show notes for people to follow up after they've listened to this. I feel quite privileged to be in part of maybe, maybe part of one of your geeky chats. I'm not sure whether this goes far enough to be defined as one of those, but it's been really interesting talking to you both today. In CBT, as you know, we like to summarize and think about what we're taking away from each session so in time-honoured fashion, what key messages would you like to leave or message would you like to leave folk with regarding this work in the perinatal period? Sarah: I think for me, it's remembering the honour we have of supporting clients in this hugely transitional period. It's such a big life transition and we have this very unique opportunity to be part of that, to be part of people's story and part of what helps make this an easier time for people and really supporting them with that distress. So I think for me, it's that, I guess, gratefulness I have to for allowing me to be part of their journey. I think, you know, in terms of my personal kind of piece, that would be what I would take. And in terms of clinically kind of taking away as like, man, involve the wider system. So involve partner, involve baby, you know, really bring people in and do the evidence-based work. Don't avoid doing treatment in pregnancy. People really deserve to get that support. Rachel: Fantastic. Anything to add Heather? Heather: I guess I would just say that although on the one hand we've talked about the struggles and barriers that might be in place to delivering care, to also highlight that the perinatal period is often a period where people are looking for opportunities for improvement. They're motivated to change behaviours or beliefs. So there's a real open-door opportunity that we have here if we work past some of those other barriers. This can be such a rewarding point in which to work with people and as we've been highlighting throughout, it has ripple effects. If there's an opportunity to bring in more individuals and to really be very profoundly impacted. Rachel: Thank you, Sarah. Thank you, Heather, for all your time and giving us the benefit of your knowledge and experience in this area. And I hope folk have really picked up some ideas about how they can enhance their practice, maybe new knowledge areas that they can push into to inform themselves, to really help us help folk in this vulnerable, but really exciting and formative period in people's lives. And thank you all for listening. Until the next time. Look after yourselves and look after each other. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. 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