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Keywords:

  • advocacy;
  • maternal psychiatric illness;
  • mother;
  • perinatal;
  • psychiatric disorder

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Motherhood is a challenging role and a life-changing experience. For women living with psychiatric illness, the challenge of motherhood is amplified. Psychiatric illness (including schizophrenia, affective and personality disorders) is associated with multiple adversities that can impair the capacity to parent. Social adversity, fluctuating symptoms, and medications and their related side-effects, can create difficulties for the new mother as she adjusts to her role. The risk for relapse among women who are unwell is heightened during the post-partum period. For many other women, the post-partum period is when psychiatric symptoms emerge for the first time. Equally important are the continuing concerns pertaining to infant well-being where maternal psychiatric illness is present. For mothers who exhibit symptoms at this time, a very real threat of protective removal exists. In the mother–infant setting, child protection legislation is biased towards the rights of the child. While there are cases for which this bias is clearly appropriate, there are less clear situations from which the infant is removed with little regard for the mother. Often mothers with psychiatric illness struggle to meet the cognitive, emotional, and financial demands of drawn-out custody proceedings. For these mothers, there is a paucity of appropriate support available, as will be evidenced throughout the present paper. There is an urgent need for professional advocacy to support women who are unwell in their transition to motherhood. The mental health nurse is able to fill a key advocating role in the perinatal psychiatric setting. Nurses in this role hold a unique position whereby social and community supports can be activated, while guidance is imparted from a ground-level standpoint. The nurse in this role has the capacity to liaise with authorities, negotiate service provision, and ensure that key parenting skills are acquired by the mother as she works to secure her role. Through the provision of proactive advocacy during this time, the nurse has the potential to ameliorate the outcomes of mothers who are unable to cope alone and the well-being of their infants.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Post-partum mothers suffering from psychiatric illness are a disadvantaged group. These women tend to have poor support networks and are often ill-equipped to deal with child protection services. Additionally, this vulnerable group is disabled even further by inadequate community supports. There is a lack of understanding about psychiatric disorders and the needs of those who are affected. Consequently, mothers who are unwell live with associated stigma and needs that remain unmet. The present article will discuss the issues surrounding maternal psychiatric illness during the post-partum period. Vignettes from the case load of a clinical nurse specialist will illustrate some of the issues that are commonly faced, while highlighting the critical role that advocacy can play in facilitating positive outcomes. The article will conclude with key recommendations for effective advocacy in the perinatal setting.

ADVOCACY

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Advocacy involves action beyond an advisory stance. Advocacy is about working alongside a mother who is unwell towards upholding her parenting and individual rights. The mental health nurse is often the primary interface between mothers with psychiatric illness and social agencies, including child protection authorities. The nursing role carries the responsibility of providing help and empowerment to vulnerable mothers who are unable to manage alone. In practice, case management for the mental health nurse comprises therapeutic and service brokerage elements. Under this model, referral and connection with appropriate services takes place alongside psychoeducation and therapeutic support. For support to exert an impact however, a considerable amount of advocacy is required in addition to traditional nursing.

Mothers with serious psychiatric illness are often engaged by child protection authorities, either antenatally or while in hospital after birth has taken place. A good working knowledge of the child protection system and close working relationship with appointed social workers are essential to nurses working in the perinatal setting. When there is clear risk to the infant, health-care professionals are required to notify child protection agencies. The mental health nurse must then advocate by providing support to the mother throughout the proceeding and necessary assistance to child protection workers. A firm grasp on counselling technique is another prerequisite, as child removal is invariably accompanied by grief and/or trauma. It is important to support the mother through the immediate crisis, containing her distress such that the symptoms remain manageable. A structured framework can then be established for the mother within which targeted advocacy can commence.

BECOMING A MOTHER

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Motherhood is accompanied by changes in self-concept, occupation, and interpersonal relationships. When women first become mothers, they will have expectations of themselves, their infants, and their maternal role. Psychiatric illness is seldom expected; however some women find themselves unable to cope as the experience of motherhood begins to unfold. Sleep disturbance while breastfeeding is often unavoidable, and for many previously healthy women, the emergence of psychiatric symptoms can occur at this time (Leathers et al. 1997).

Social support can buffer against psychotic symptoms and help the mother to focus her attention on the infant within the containment of another. (Fleming et al. 1992; Mares et al. 2005). Role modelling, emotional support, and practical assistance are benefits that can be derived from the presence of social supports (Reupert & Maybery 2007). Mothers in crisis are more likely to lose custody of their children if they have poor support networks (Ackerson 2003; Howard et al. 2003; Reupert & Maybery 2007). Conversely however, mothers with psychiatric illness can experience additional stress when the social supports that are available to them are intrusive and/or controlling (Nicholson et al. 1998). For the mental health nurse, a crucial task of advocacy involves activating the mother's social supports, and where necessary, protecting against toxic social influences.

WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

The onset of many psychiatric disorders is during the peak childbearing years, contributing to impairment for affected new mothers (Altshuler et al. 1998; Kerfoot & Buckwalter 1981; Mowbray et al. 2005). Coping with the onset or relapse of psychiatric illness is difficult for patients at the best of times. For the post-partum mother in this situation, difficulty will be compounded by concurrent demands of adjusting to the new tasks of parenting (Diaz-Caneja & Johnson 2004; Park et al. 2006). For an existing disorder, preventative management can be complicated in many cases, particularly when medication may need to be withdrawn during pregnancy to avoid teratogenic effects or toxicity to the infant while breastfeeding (Akdeniz et al. 2003; Nordon et al. 2007). For women with schizophrenia or psychotic features, the acquisition of necessary parenting skills may also be hampered by associated cognitive impairment (Fitzgerald et al. 2004; Green 1996; Miller & Finnerty 1996; Heinrichs & Zakzanis 1998).

Mothers with psychiatric illness can present with numerous factors that pose risks to their infants, particularly in cases where the illness is severe. The symptoms of illness, poor support networks, and chaotic lifestyle patterns that can accompany illness have the potential to impair parenting during the post-partum period (Park et al. 2006; Reupert & Maybery 2007). While parenting, life, and living skills can often be facilitated, socioeconomic variables and unsuitable accommodation can make it difficult for the mother with an infant in her care. Consequently, concerns pertaining to parenting capacity can arise during contact with antenatal clinics, community services, and early infant clinics, attracting scrutiny from child protection authorities. Mothers living with a psychiatric illness are significantly overrepresented in protective care proceedings relative to the population prevalence estimate for psychiatric illness (Llewellyn et al. 2003).

SEPARATION AND REMOVAL

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Care proceedings for new mothers with psychiatric illness can lead to poor outcomes. One study reported that only 20% of mothers retained full custody of their children following hospital admission in the USA (Joseph et al. 1999). In an earlier study (Coverdale & Aruffo 1989), it was reported that in a sample of psychiatric patients, only 40% were the legal custodians of their children. Similarly, a UK study (Kumar et al. 1995) reported that within a sample of women with schizophrenia, only 50% retained custody after being discharged from conjoint mother–baby care. Comparable figures persist to date (Diaz-Caneja & Johnson 2004; Howard et al. 2003).

The children of women affected by psychiatric illness can experience delay in their physical, social, and emotional development as a result of poor practical nurturance, mother–infant interaction, and attachment formation during the first year of life (Murray et al. 1996; Riordan et al. 1999). It is suggested, however, that while longitudinal effects on children are marked in some instances, the majority of affected mothers are able to parent adequately in the presence of appropriate supports (Howard 2000; Oates 1997; Scott 1998). Unfortunately however, the supports we have in place are neither adequate, nor in all cases appropriate for the needs of families headed by a mother with a serious psychiatric illness.

For the needs of this group, service provision is fragmented. Expertise in mental health and parenting support is not common in practice, rendering it difficult for mothers to receive support that is appropriate. Many services refer on to child protection agencies as a result of this shortfall, where difficulties continue for these mother–infant pairs. Inadequate linkage between mother–infant services and psychiatric care serves to widen the gap between what is required and what is available for supporting the dual needs of this group. In a case-note review of the care provided to 58 deinstitutionalized mothers in Leicestershire, UK, little evidence of attention to the parenting role was apparent throughout the record of their psychiatric care. For several mothers, the presence of offspring was not referred to within case notes (Dipple et al. 2002).

When referred on to child protection agencies by services, the needs of unwell mothers remain largely unmet. When parenting is impaired due to serious psychiatric illness, child protection workers are faced with limited options, and often the removal of the infant is seen as the only available alternative in order to ensure safety when referral takes place. The interests of the child are held paramount in decision making, with the ill-supported mother treated as a potential source of risk. The mother in this situation will seldom have the professional support that is required to demonstrate a ‘good enough’ standard of parenting to external protective agencies (Diaz-Caneja & Johnson 2004).

When faced with a need to assert their parenting rights, mothers in this situation essentially have no one to ‘bat’ for them.

Advocacy on the part of the mental health nurse is crucial for mothers involved in child protection proceedings. It is necessary in such cases to develop appropriate management plans that take into account the mother and baby. Advocacy in situations where there is a potential for risk can involve early intervention that links the mother with services, clinical care, and community supports before the point of crisis is reached (Bu & Wu 2008). In such a way, the mental health nurse can minimize unnecessary removal and assist in restoration where parenting is adequate.

THE IMPACT OF CHILD REMOVAL

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

When removal occurs, separation affects both mother and child. Mothers experience grief, loss, and exacerbated symptoms. Outcomes for children in out-of-home care are comparatively poor in several crucial developmental areas, including language acquisition (Stock & Fisher 2006), emotional and social adjustment (O'Neill 1999), mental health (Tarren-Sweeney & Hazell 2006), academic attainment (Delfabbro et al. 2000), and physical health (Maunders et al. 1999). During times of adversity, the infant relies on a sensitive, responsive, and available figure for external regulation and emotional comfort (Ainsworth 1978; Bowlby 1973; Bowlby 1982). In the absence or disruption of healthy attachment, social, emotional, and physical sequelae can follow for the infant (Carlson et al. 2003; Hawley & Gunner 2000; Trevarthen 1993). Out-of-home care affects many aspects of infant development and correlates with a high rate of disorganized attachment (Vorria et al. 2003) and a low rate of secure attachment to non-parental caregivers (Ahnert et al. 2006). Where custody is either initially retained or later restored, an important role for the mental health nurse includes facilitating the development of healthy attachment. Through the provision of support and timely intervention, this relationship can potentially be preserved.

While out-of-home care does not automatically protect children from adverse outcomes, it needs to be acknowledged that in some cases, the termination of parenting rights is essential to prevent abuse or neglect from occurring. While acknowledging this, it still must be recognized that defensive practice motivated by the adverse publicity associated with harm to infants is increasing (Lindsey 1994; McConnell et al. 2006; Scott 1995; 1998). Decisions guided by a purely ‘better safe than sorry’ approach need to be avoided in cases whereby good enough parenting can be facilitated. From a clinical standpoint, the decision to remove a baby can occur before appropriate management has been formulated. Further damage to the mother–infant relationship results from separation during lengthy child protection proceedings. Outcome studies show that although immediately pragmatic, removing the child from a mother who is unwell is in very few instances a productive response and not a lasting solution in guarding against risk (O'Neill 1999; Tarren-Sweeney & Hazell 2006).

THE PLIGHT OF UNWELL MOTHERS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

When under the notice of child protection services, vulnerable parents are required to function at a very high standard (Diaz-Caneja & Johnson 2004; McConnell & Llewellyn 2002). Mothers are expected to be ‘good’ mothers; ‘good enough’ parenting is no longer enough (Winnicott 1965). With a low threshold for inadequacy, it is difficult for a symptomatic mother to prove that she is competent. When faced with the need to meet these high standards, advocacy is the lifeline that will enable the mother who is unwell to demonstrate her worth as a parent.

The following vignettes highlight key difficulties faced by post-partum mothers with psychiatric illness, and the ways in which advocacy can facilitate better outcomes:

CASE STUDY 1: M.A

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

M.A was a first-time mother with no support network. She had experienced a history of homelessness and drug abuse. Her partner demonstrated little interest in the pregnancy, the expectant mother, or future parenthood. Family connections had evaporated over time due to M.A's transient lifestyle, drug use, and choice of partner. M.A had a diagnosis of schizophrenia, exhibiting a paranoid delusion with accompanying anxiety. After childbirth, M.A required a period of hospitalization for her persistent psychotic symptoms. Following treatment, parenting support was provided in a community facility. Initially, M.A demonstrated the ability to be mindful of her infant and developed capable mothering skills.

Unfortunately however, a baby monitoring device was utilized to check on M.A during the times that she was alone with her infant. This proved stressful for M.A and exacerbated her paranoid state. Silent and impoverished interactions between M.A and her baby were then noted by staff at the facility.

The effect of the listening device upon M.A's symptomatology undermined the extent to which she was able to interact with her infant, eliciting unfavourable judgement regarding her ability to parent.

Earlier reports showed that M.A's mother–infant interactions had been markedly more positive than they now appeared.

As interaction suffered and negative feedback continued, M.A's condition continued to deteriorate, until finally her baby was removed. It was subsequently a long and arduous process to demonstrate that this mother was capable of interacting with her baby.

In the absence of duress, the interactions between M.A and her infant were easily classifiable as ‘good enough’. The advocacy provided for M.A in order to have her baby restored included: staff education regarding the concept of ‘good enough’ parenting (and the ways in which M.A's parenting fulfilled this criteria); clarification that ill-framed criticism of M.A constituted a form of high expressed emotion (known to exacerbate psychotic symptoms), and the inappropriateness of a listening device for a patient who suffers from paranoid thinking.

M.A and her baby are now in the community with good support and ongoing supervision.

CASE STUDY 2: M.B

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Upon presentation, M.B was in a state of crisis. At 36 years old, she had just given birth to her second child. M.B had a history of depressive illness and was concurrently receiving counselling for drug and alcohol dependence. M.B had an adequate support network, but was estranged from the biological father of her infant due to his violent behaviour and drug abuse.

M.B had self-presented to a treatment facility in order to gain professional help with her infant following threats from the biological father. The infant appeared appropriately dressed and cared for, with no nappy rash apparent and meeting all appropriate developmental milestones. A routine call, as per protocol, was made to child protection services, and a worker arrived within 24 hours. A distressing scene followed, with a distraught mother and the protective officer aggressively challenging for the baby. The infant was removed from the mother's care as there was a potential for harm perceived.

It was a difficult removal, proving traumatic for both the mother and the attending medical and psychiatric staff.

It was not possible to work with this mother for some weeks initially, as the removal had proven debilitating for M.B. Treatment and the management of M.B's mental health was impracticable due to her acute distress regarding her infant's well-being while in the custody of strangers. Many trips to solicitors and to court made it difficult for this mother to see her treating team. Child protection appointments became the priority. While regular follow up was recommended for M.B, it was important to be flexible initially while legal issues were settled. It was difficult for M.B to obtain visits with her baby and also problematic trying to locate an available rehabilitative placement, without which restoration would not be granted to M.B.

Advocacy for M.B involved arranging legal services, providing support in court with recommendations, connecting her with appropriate intervention, and providing regular and reliable follow up. M.B.'s infant was eventually restored to M.B after a lengthy process, and continues to thrive in her care. M.B receives ongoing support from psychiatric and rehabilitative services.

CASE STUDY 3: M.C

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

M.C was a 22-year-old woman with a history of melancholia. She was a first-time mother living in supported accommodation and had previously experienced homelessness. M.C had poor family support, a history of childhood abuse, and a close family member involved in dealing illegal drugs. M.C's baby was conceived through sexual assault. She exhibited poor self-esteem, self-harming behaviour, chaotic thinking, and a disorganized lifestyle.

Despite her difficulties, it was clear that M.C cared for her baby appropriately and showed no signs of intent to inflict any harm.

Subsequent to a perceived crisis (a family member seeking custody of her baby while she was confined to hospital), M.C became overwhelmed and carried out an episode of self-harm while her baby was in her care.

M.C lost custody of her baby and regressed into behaviour that compromised her safety. Initially struggling to grasp the danger of the environment to which she had subjected her infant, M.C was filled with immense anger regarding the removal, holding that she had not, in her own belief, harmed her baby directly. A rehabilitative facility was found for M.C and admission was planned, but did not eventuate due to unforeseen closure.

This created a situation of powerlessness for M.C, deepening her chaotic behaviour.

The effort to contain M.C's distress proved challenging, as her initial response was to disengage from psychiatric and mental health services.

With ongoing support, M.C's health is steadily improving, with incidences of self-harm diminishing. M.C requires support and advocacy when interacting with the child protection authorities, as she perceives mixed messages and ambiguous information concerning the future outcome of her case. Court proceedings are ongoing, and M.C's baby remains in foster care.

The search for an appropriate residential facility for M.C continues. M.C is seeking to replace her loss with plans to conceive again if her baby is not restored to her care. There is potential for a positive outcome for this mother and her infant; however, this remains contingent upon the attainment of the right support for her now.

DISCUSSION: MESSAGES FROM PRACTICE

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

The vignettes point to a number of service gaps that often contribute to the poor outcomes experienced by mothers with psychiatric illness.

Child protection proceedings are predominantly biased towards the child, with minimal consideration for the rights of the mother. The well-being of both the mother and her baby are equally significant, and while mandatory reporting for children at risk is legislated, both the mother and baby require appropriate care. This imbalance is exemplified by the case of M.A. Monitoring was continued during periods of play despite the harm this was causing to the health of the mother. Similarly, M.B's escalating depression worsened during the separation from her baby, with authorities making it very difficult to obtain visits with her baby.

Within a recent study concerning parenting with a psychiatric illness, 50 affected mothers commented on professional intervention in relation to their young children (aged 0–10 years). A key finding was that when children were removed, a very distant relationship with the social authorities followed, much the same as experienced by M.B after her baby was removed (Wang & Goldshmidt 1996). Dipple et al. (2002) found that, of the children separated from their mothers who were unwell, 37% had no further contact following removal, and that not enough information was available to enable contact following separation (Dipple et al. 2002). As depicted in the three case examples presented earlier, care proceedings in their current form are disruptive, time consuming, and detrimental to both the mother and infant. Limited care is afforded to the mother throughout the process, and even less to the developing attachment relationship.

Of the women interviewed by Wang and Goldshmidt (1996), approximately one-third expressed a need for professional support, but reported that they were not receiving any. A lack of residential availability meant that M.B's reunion with her infant was delayed, causing her focus to be averted from her own mental health. Similarly, limited rehabilitative care delayed the restoration of M.C's infant. Dipple et al. (2002) found that almost 75% of women separated from their infants spent comparatively longer in hospital after separation than before. They suggest that this could indicate the damaging effect that child removal has on the post-partum mother (Dipple et al. 2002). The length of separation worsened M.C's illness. It is often the case that when time is lost during separation and decision making, difficulty with attachment emerges upon restoration. Some mother–infant pairs are forced to wait for up to 3 months before an appropriate facility becomes available, during which time valuable treatment and intervention opportunities are lost.

Mother–baby units are urgently needed in order to provide appropriate care for mothers in need. Within psychiatric, obstetric, and publicly-funded units in Australia, there is a shortage of facilities specific to mother–infant pairs, particularly within New South Wales. Some existing approaches to care of these dyads tend to exacerbate illness, such as in the case of M.A.

Mothers often feel that there is no clear process by which they can construct a case for restoration. The legal processes are bewildering for the mother, with an absence of clear guidelines and opportunities to demonstrate competence. The vignettes demonstrate that intervention occurs for the most part during crisis, by which time removal is the only viable solution due to a lack of assistance ‘before everything is in a mess’ (Wang & Goldshmidt 1996; p. 58). There is little available support in between the extremities of service inaction and protective removal. The case of M.B exemplifies this limited response availability. M.B's baby was removed by child protection authorities in response to her request for help. The clear absence of abuse or neglect to her baby did not alter the course of action that was taken. M.B's case was managed with the same solution (i.e. removal) as is utilized for cases of physical harm and neglect. Alternative forms of intervention were not offered to M.B. Feedback from mothers with psychiatric illness indicates that more practical parenting support is desired, along with help to maintain the emotional well-being of their children (rather than the monitoring and disruption to the relationship that is more typically imposed during times of need) (Wang & Goldshmidt 1996).

RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Child protection concerning maternal psychiatric illness is an area that is fraught with difficulties. No two families present with the same circumstances, and no one solution is able to address all individual needs. The clinical setting requires a secure and supportive framework, containing well-defined plans for crises. Following assessment, mothers should be actively engaged by a multidisciplinary team, as her areas of strength and limitation are identified and future intervention planned. Clear guidelines that will clarify the expectations of child protection agencies are recommended, especially regarding the requirements of ‘good enough’ parenting.

Step-down units for mothers and infants are urgently needed in order to negate much of the anger, hypervigilance, helplessness, and disempowerment felt by mothers who are waiting for placements. The acuity of a mother's illness may influence the extent to which she will engage with service providers. Mothers advise that trust is needed if the professional alliance is to work. They express a desire for open communication, as well as an awareness of the difficulty of receiving advice about their own children (Wang & Goldshmidt 1996). Adequate resourcing and appropriate staff training are areas of need within the clinical setting. As highlighted earlier, this is indeed another way in which contextual factors are currently adding to the disability of vulnerable parents (Reupert & Maybery 2007).

A focus on prevention and early intervention is recommended. Mother–infant pairs experiencing hardship associated with maternal psychiatric illness are better served longitudinally by available and appropriate supportive facilities. Expedient and transparent assessment and planning are recommended to maintain the mother–infant pair. Findings relating to the outcomes of children in care (Delfabbro et al. 2000; Maunders et al. 1999; O'Neill 1999; Stock & Fisher 2006; Tarren-Sweeney & Hazell 2006) suggest that the biological mother should be considered an infant's first option as caregiver wherever viable. There is an opportunity for the mental health nurse to advocate in this respect, by securing an adequate level of support for the mother. Mothers with psychiatric illness express a desire for psychotherapy for their children, respite for themselves, counselling for marital issues, health visitors, and practical help in the home (Wang & Goldshmidt 1996). Enabling a mother's improvement will provide her with the opportunity that she requires to parent her children to the best of her ability.

CONCLUSIONS: ADVOCACY IS KEY

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

In supporting new mothers with psychiatric illness, advocacy is a core area of need. Although resources are limited, a whole-system approach must be used if outcomes are to improve. The issues surrounding mothers with psychiatric illness are complex and challenging for any service provider. Enhanced coordination within the health-care system is required in an approach that is collaborative between disciplines, and in all cases, inclusive of the mother. Care offered to women affected by psychiatric illness in the perinatal period can form an essential part of present and future self-concept throughout motherhood (Bu & Wu 2008; Casiano & Hawkins 1987).

CORE ROLES IN CLINICAL ADVOCACY

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES

Clinical advocacy for mothers with psychiatric illness is a role that is both challenging and composite in nature. Advocacy will in most cases commence during an emotive stage for the mother and her infant. At this time, the mother will be overwhelmed by numerous demands and expectations. Managing these external demands on behalf of the mother can be containing, as well as protective against potentially detrimental stressors. With the mother adequately supported, a safe nurturing environment for the infant can be facilitated. Key examples of practical advocacy are outlined:

  • 1
    Identify key areas of need for the mother-infant pair, such as:
    • • 
      A respectful and honest working relationship
    • • 
      An appropriate nurturing environment
    • • 
      Psychiatric services and ongoing clinical support
    • • 
      Monitoring of medications and related side-effects
    • • 
      Liaison with child protection services
    • • 
      A comprehensive management plan that includes relevant agencies
    • • 
      Activation of community supports
    • • 
      Home midwifery for discharge planning
  • 2
    Establish and seek out available resources
    • • 
      Community mental health services
    • • 
      Community child and family services
    • • 
      General practitioner
    • • 
      Parenting education programmes
    • • 
      Early intervention programmes
    • • 
      Support groups
    • • 
      Ongoing review and identification of service deficits
  • 3
    Court and legal processes:
    • • 
      Offer support at interviews with child protection services
    • • 
      Obtain guidelines of legal and court processes for the mother
    • • 
      Liaise with appointed solicitor (with consent)
    • • 
      Provide supportive documentation
    • • 
      Ensure patients understand their rights
    • • 
      Establish a visitation schedule
    • • 
      Ensure that the visitation rights of the mother are upheld
    • • 
      Document the details of key contact persons for the mother

Mental health nurses and obstetric units are becoming increasingly mindful of facilitating the natural bonding process and providing advocacy for new mothers with psychiatric illness. It is hoped that this process will eventually be supported through future targeted policy making and funding. At present, however, the focus remains with disseminating the challenges faced and elucidating the importance of proactive advocacy.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. ADVOCACY
  5. BECOMING A MOTHER
  6. WHEN PSYCHIATRIC ILLNESS AND MOTHERHOOD COLLIDE
  7. SEPARATION AND REMOVAL
  8. THE IMPACT OF CHILD REMOVAL
  9. THE PLIGHT OF UNWELL MOTHERS
  10. CASE STUDY 1: M.A
  11. CASE STUDY 2: M.B
  12. CASE STUDY 3: M.C
  13. DISCUSSION: MESSAGES FROM PRACTICE
  14. RECOMMENDATIONS FOR SERVICE PROVISION IN THE PERINATAL MENTAL HEALTH SETTING
  15. CONCLUSIONS: ADVOCACY IS KEY
  16. CORE ROLES IN CLINICAL ADVOCACY
  17. REFERENCES
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