Recovery

In mental health services the term “recovery” has been all the rage for the last few years. Australia’s mental health services are encouraged to be “recovery orientated” and use the “recovery approach” or “recovery model” [same same]. In fact, Australia’s 2010 National Standards for Mental Health Services embed the recovery model in clinical practice [see here]. This is a move away from seeking to “cure” the individual. It is a move towards supporting the individual on their journey towards healing.

The recovery model emphasises hope for the person who is experiencing mental illness. Ingrained in the recovery approach is encouragement for the individual to increase their understanding of both their abilities and their disabilities, and to take-on as much autonomy as possible. The person can then use hope, insight and autonomy as a platform to engage in an active life – one with purpose and meaning – and thereby acquire and sustain a more positive sense of self.

All good stuff. What’s not to like?

Well, the recovery model assumes existing psychiatric disability and/or psychopathology, but in perinatal mental health we’re trying to head problems off at the pass. Recovery is a journey towards healing, but perinatal mental health seeks to decrease either the need for that journey or, at worst, that the journey is not too long or too complex. “There’s nothing to be gained from waiting for a pregnant woman or new mother to be in crisis before intervening, but there is much to be gained in preventing symptoms becoming severe or debilitating.“# So, if we’re doing perinatal mental health prevention and early-intervention the recovery model isn’t a great fit – we’re trying to avoid the level of acuity or chronicity that the recovery model caters for.

However, we don’t want to throw the baby out with the bathwater [dud idiom for a perinatal mental health nurse to use – sorry about that]. Recovery enshrines the uniqueness of the individual, that the individual will be treated with dignity and respect, that the individual will be empowered to make real choices, and that clinicians work in partnership with the individual and ensure that communication is a two-way street. We want to keep all those values from recovery and prevent symptoms/disability from becoming severe or long-lasting.

That’s why i suggest we start making-up words (a practice often classed as psychopathology in my business: look-up the word “neologism“). Anyway, undeterred, here’s a neologism I prepared earlier: “precovery” – please, let me explain:

Prehab

In October 2012 I attended a Health Roundtable workshop in Sydney. There were some really bright people from all over Australia and New Zealand there, representing just about every speciality in health care. During a break a I got chatting to a Physiotherapist, Judy Chen, who introduced me to the word/concept of “prehabilitation” or “prehab”. Prehab is where the patient is taught and practices the skills and exercises that s/he will required for post-operative recovery before the operation.

For example, let’s pretend that you require an operation on your right knee which will leave you on crutches for a week afterwards; you must avoiding twisting movements, but to maintain a full range of movement after the healing is completed, you’ll need to bend the knee and partially weight-bear as soon as possible post-op. Wouldn’t it be better to get accustomed to using crutches and practice the movements/exercises required when you’re not experiencing post-surgical pain, and you don’t have IV drips, drains and wound dressings hampering your mobility? That’s the premise of prehab; practice the exercises and/or using a mobility aid while in comparatively good shape, so when you’re in not-such-great shape you won’t have to be learning a new skill set from scratch.

Prehab is a good idea, eh?

It’s OK for perinatal mental health nurses to shamelessly steal ideas from physios, isn’t it?

I hope so.

Precovery

Perinatal Mental Health Precovery would borrow the prehab idea, and encourage pregnant women and new mums to acquire supports and practice skills before symptoms of depression and anxiety arise. Precovery will be built-in to antenatal care: just part of the everyday health service routine.

So, what would precovery include? Well that’s where I’m looking for input – I’m really hoping to draw on the wisdom of others to come-up with a more complete, more rounded-out notion as to what to include in precovery.

Reflecting some good clinical practices I’ve been exposed to/heard about, here are some of the components I’d suggest for Perinatal Mental Health Precovery:

[Precovery 1] Create or Reinforce Support Networks

Antenatal and Parenting classes – for most women I’ve spoken to, the content/information in the classes is less valued that the relationships/contacts made with other parents. The notion of “teaching” and “learning” is a bit of a smokescreen for the really valuable stuff: “connection” and “attachment”.

Playgroup – as long as it’s a supportive, friendly playgroup. Some of the mums I’ve met tell me that some playgroups can feel a bit competitive, and give their sense of confidence a bit of a bruising. To quote a delightful lady I met with a few times, “You know those f#@*%^g Lorna Jane mums? The perfect ones who look great, have babies that sleep well and breastfeed like champions? The playgroup I went to was full of them. And then there was milk-soured, frumpy, messy me with mastitis and a bottle-fed baby. It was awful. I felt worse. I had to stop going.”

Targeted supports – eg: teenage mums will almost certainly feel much more comfortable, better supported, if they get to meet with other young women who are pregnant/have new babies.

[Precovery 2] Informed & Supportive Significant Others

A supportive partner can have an incredibly positive influence; traditionally that is baby’s father, but families come in all shapes and sizes now – the supportive partner isn’t always a bloke, and there’s not always one on the scene. When baby’s father is on the scene, let’s get him worded-up on how important he is to both mother and baby. The beyondblue “Hey Dad” booklet can get the conversation started. In same-sex relationships, maybe grab the same free booklet, and a bottle of liquid paper and a pen… or (more seriously) connect with others who share your experience – there are some good online forums available, try the Raising Children Network for instance.

If baby’s Dad isn’t around, we need to go looking for a family member(s) or close friend(s) who can step-up and share some of the good, and not so good, stuff. Single parent families are the fastest growing type of family in Australia; some resources and agencies are responding to that better than others – more info here.

[Precovery 3] Symptom Awareness/Monitoring

This will happen to some degree with the universal screening as recommended by the National Perinatal Depression Initiative, and/or via regular contact with GP/Midwife/Obstetrician/Child Health Nurse/Perinatal Mental Health Worker/other clinician.

It is also worth encouraging people who experience depression, anxiety or other mental health difficulties in the past to have a good awareness of what their early-warning signs of relapse are. Significant others can play a part in this too. The online, self-scoring version of the Edinburgh Postnatal Depression Scale could also help some people keep an eye on things. For instance, I encourage many of the women I meet with to visit this site regularly (but not too frequently): justspeakup.com.au/epds Ask the woman’s significant other(s) to use it too – perhaps make a diary date for the first of each of month. This self-awareness/self-monitoring fits nicely with the empowering aspects of recovery, so certainly belongs in precovery.

[Precovery 4] Easy Access to Appropriate Information & Support

Often the supports that help the most aren’t specialist mental health supports. In my clinical experience many Mums have found an approachable Midwife or a friendly, relaxed Child Health Nurse has done more practical stuff to decrease anxiety than weeks of “talk therapy” could ever achieve. Practical parenting supports need to be easy to find – having an online presence, such as Parentline and Tresillian, is part of being easly accessible.

Sometimes the support required will be catered for by phoning the Post & Ante Natal Depression Association (PANDA) on 1300 726 306, and/or a visit to the PANDA website

Other websites such as beyondbabyblues, Just Speak Up, Black Dog Institute and mindhealthconnect are worth visiting, as are some of the grassroots supports that have sprung-up on Facebook – pages such as Daisy Chains Postnatal Support Network and Peach Tree Perinatal Wellness, amongst others.

Hopefully there will be specialist mental health support available in most health districts. Where there isn’t a perinatal mental health service GPs and local mainstream mental health services/clinicians will need to plug that gap as best they can.

[Precovery 5] Recognition of the Uniqueness of the Individual

This will assist us to resist the temptation to imagine “one size fits all’ solutions to complex, individualised circumstances. The values and the goals of the individual will determine what, if any, support is required.

Part of this will require health services to promote realistic expectations. Health services will make sure that families have heard of Donald Winnicott’s concept of “the good-enough mother”, and that those books which prescribe baby or parent behaviour are left in the bookshops just as they should be: unsold and dusty. Let parents know what to expect: if 25% of births end-up as emergency caesarean at this hospital, make sure that’s known: “There are 16 pregnant women in this antenatal class – a bookmaker would take a bet that 4 of you will have an unplanned caesarean section. If you happen to be one of those 4, how will that match-up with your hopes and expectations? Will it mean that you’re a ‘bad mother’ or ‘a failure’?” We need to be proactive about managing idealised, unrealistic versions of the pregnancy/parenting story.

[Precovery 6] Making Real, Informed Choices

This does carry the risk that the clinician’s recommendations are not always followed [see Exhibit A: the cigarette smokers]. However, it carries the benefits of avoiding coercion and inadvertently causing harm by disempowering the individual. Advocating for real, informed choices puts the clinician on a more realistic footing too. Let’s not even entertain the fantasy that every pregnancy/birthing/parenting experience will be ideal – we’re not aiming for perfection, we’re aiming to minimise harm. Bottle feeding works better for your family than breastfeeding? No judgement, no coercion, no worries – shall we run through bottle preparation together? Dignity and respect are also straight out of the recovery model – let’s include them in precovery too.

[Precovery 7] Partnership & Communication

As with advocating for real choices, these are the qualities that will build resilience and trust. Part of precovery will be to provide the individual with opportunities to ask questions and ventilate concerns, and to be supported by the clinician to explore the solutions together.

The other bit of partnership and communication is with the new baby. Let parents know that babies are born with a brain primed for experience, and ready to socialise and learn from day one. Show something like the Getting to Know You DVD in antenatal classes so parents can ready themselves for the communication part of early infancy. New parents may not be aware of baby’s capacity to socialise, learn and explore from the get-go – it would be cruel not to let them in on the secret. That information may, in turn, strengthen the partnership and the quality of attachment between baby and her/his primary caregivers.

Ideas? Comments?

That’s my little brainstorm on what precovery should include. What have I missed? Is this idea of “precovery” as a way to frame perinatal mental health early-intervention and prevention strategies a nutty neologism or a nifty notion?

Please add your thoughts/suggestions in the comments section below.

Paul McNamara, 5th March 2013

Reference

McNamara, P. (2011) Perinatal mental health, O&G Magazine, Vol 12, No 2, Winter 2011, pp 56-7. http://www.ranzcog.edu.au/publication/oandg-magazine/editions/cat_view/38-publications/409-o-g-magazine/410-o-g-magazine-editions/538-vol-13-no-2-winter-2011.html [tragically, shamelessly, self-refrencing again: please note that the “Dr” afforded me in this paper is a typo in the magazine – I don’t have a PhD]

Post Script (added 6th July 2013)

Kay McCauley, Senior Lecturer at the Monash University School of Nursing and Midwifery, suggested that I tidy-up this blog post so it would be suitable to publish in a journal. To be honest, I never would have thought of doing so without Kay’s prompt, and am very grateful to Kay for her encouragement and support. The waffly ramblings above were tidied-up and abbreviated to meet the ANJ word limit (I recruited Kay to help with the slash and burn as co-author).

Anyway, I just found out this morning that it has been published. Yay!

Here’s the citation, link and PDF:

McNamara, Paul and McCauley, Kay. (2013). ‘Precovery’: A proactive version of recovery in perinatal mental health. Australian Nursing Journal: , Vol. 21, No. 1, Jul 2013: 38.

http://search.informit.com.au/documentSummary;dn=396717147073212;res=IELHEA

PDF: ANJ