An Interview with Our Guest Contributors, Dr. Josephine Harrison and Dr. Panos Vythoulkas

1. Can you share some of the most rewarding moments or highlights from your careers as Clinical Psychologists in the NHS?

Josephine: The most rewarding moments have been when I have had the time and flexibility to complete therapy or work with the same person over multiple episodes of care. Continuity of care is fundamental for many parents during their obstetric journey; for example, helping someone who has lost a baby through a subsequent pregnancy. This continuity is also crucial for people with complex physical health needs or life-limiting conditions. I feel privileged to be allowed into people’s experiences of birth and death and have learned so much from this. I also greatly enjoyed being a Schwartz Round facilitator, which aims to help all staff reflect on their experiences at work.

Panos: Providing bespoke psychological and psychotherapeutic interventions to people who wouldn’t otherwise have access to them for free, thanks to the NHS, is incredibly rewarding. This includes parents and babies from deprived areas of our London communities, refugees and asylum seekers, and women involved with the Health and Justice system while escaping domestically abusive relationships. I have also had the privilege of working alongside NHS colleagues from various disciplines, social care, and probation, witnessing the dedication and effort that goes into supporting and protecting the public, often at the expense of their own wellbeing. The years following the pandemic have highlighted the importance of our key workers, who came together to keep the country going, saving lives while risking their own.

2. What are some of the most significant challenges you have encountered while working with both adults and babies in your practice, and how have you navigated these challenges?

Josephine: A particular challenge has been providing a secure base for people to work from, with regular quality consulting room space. This is important for both clients and staff to feel valued, with matching chairs, floor mats, toys, and appropriate toilets. There has been considerable variability in these resources at different times and in different areas. Since the pandemic and the increased utilization of remote working, more IT support has been necessary, particularly with specialist therapy approaches like Video Interactive Guidance. Externally, the patchy provision of other services and the variation between boroughs can feel very unfair. Expectations on our workforce are sometimes unrealistic, so it is essential to look after staff to provide good quality, consistent care. Supervision, support, training, flexibility, and being human offer protection against burnout, particularly with baby loss and complex trauma.

Panos: There is still a lot to be done on a social, political, policy, and workforce development level to ensure babies’ voices are heard and their needs are considered. Unfortunately, 1 in 5 babies will witness domestic violence and abuse, which has detrimental effects on their psychosocial development. Justice-involved pregnant women are still giving birth in prison with their and their babies’ live being put at risk. Many babies and their families live in financial deprivation and are isolated from opportunities, society, and mainstream care. These babies are often missed by the system, and interventions that could prevent later emotional difficulties are not provided. We navigate these challenges through advocacy, workforce training, proactive outreach and engagement, and raising these important issues with decision-makers.

3. Given your extensive experience in various NHS settings, what changes or improvements would you like to see in policies around mental health care, particularly in terms of accessibility and quality of care for mothers, fathers, birthing people and their babies?

Josephine: I am so glad there is now wider recognition of perinatal issues in the absence of a baby, but it has taken time to establish that fathers and partners can also experience perinatal trauma and loss. Like SPMHS, the MMHSs are not commissioned to see fathers and partners, which is nonsense to me. In Maple, we decided to offer a service to fathers and partners, but due to increasing demand, we have had to cap this at only six sessions. Many MMHSs changed their names because “Maternal Mental Health Service” excluded non-birthing people, non-binary individuals, fathers/partners, people who don’t identify as parents (e.g., due to unsuccessful fertility treatment), or people who don’t identify as having a mental illness. This underlines the importance of services being genuinely co-produced, using client feedback, and including peer support workers.

Panos: I would like to see more investment in research in perinatal mental health, covering the entire first 1001 days. It is positive that we now have specialist services to help babies and their families with various difficulties through a multidisciplinary approach. We still have much to learn about what works for whom in the perinatal period and the mechanisms of psychological change, particularly for historically underrepresented populations. I would like to see specialist support for women, men, and their babies who have double contact with the justice and social care systems, reduce maternal separation where possible, and better understand the needs of Black and Asian parents and parents who are transgender or queer.  

4. You have experience supporting individuals during the perinatal period. At The For Baby’s Sake Trust, we work with parents from pregnancy until their baby is 2. What are some of the unique challenges faced by expecting or new parents in terms of mental health, and how do you tailor your therapeutic approach to meet their specific needs during this critical time?

Josephine: We also work from the time of pregnancy up until the baby is two, and so much happens in terms of the child’s development and the learning for parents. It is a time of extreme vulnerability as well as great opportunity. So many past issues are triggered by the experience of creating new life and witnessing a child grow, which can mean the renewal of past childhood/family trauma in the parents. The hormonal changes and fluctuations can destabilise mental illness biologically and bring on serious conditions like psychosis. During such an eventful life stage, we aim to keep the baby in mind (whether present in the session or not, or alive or not) and therapeutic approaches need to be individually adjusted for each family. We start with where the person is at, and with what they feel is important. I may often have variable gaps between sessions, see people online, at home, or in a health centre. I have also seen women during labour and supported them in appointments with other professionals. Being flexible and creative, and using the skills of the whole team!

Panos: The mental health challenges parents face in the perinatal period range from postnatal anxiety and depression, postnatal psychosis, difficulties bonding with the baby, complex trauma presentations which get in the way of connecting with the baby or the role as a mother, and the increasingly acknowledged impact of neurodiversity in perinatal mental health. By adopting a community psychology approach, we navigate families’ individual needs flexibly, offering home or maternity ward visits, trying to see them near where they live, and fostering connections with local perinatal groups and access to health visiting and the Family Hubs. Since the field of community perinatal mental health is still in its infancy, we continuously evaluate our practice, align our interventions with the NICE guidelines, and strive to inform our practice by conducting research and evaluation projects. Building a strong therapeutic relationship with families is at the centre of everything we do, as this often helps to navigate any therapeutic challenges as they arise.

5. Like The For Baby’s Sake Trust, your practice is grounded in a trauma-informed approach. Can you explain what trauma-informed care means to you and its importance in therapeutic work, particularly in the context of domestic abuse?

Josephine: The Hippocratic oath, “First, do no harm,” applies here. Trauma-informed care is not new, but it is often not thought about or applied sufficiently, and so many people can be re-traumatised by careless interactions and become even more reluctant to accept help or believe that help is there. It is important to listen and think about people’s situations and understand their position. I remember at the very beginning of my career the pain and outrage I felt when a teenager spoke about being shamed by professionals for being pregnant when that pregnancy was the result of abuse. I have found that it is particularly important to work on self-esteem and self-worth, as these are so catastrophically eroded in the context of abuse, despite the outward impression of being a survivor and having to cope.

Panos: Trauma-informed care for me is about going back to basics. Working on the assumption that everyone we encounter at work, service users and colleagues, will have experienced some kind of traumatic experience in their lives which will have shaped the way they understand themselves, others, and the world. Unfortunately, domestic abuse of all kinds, but predominately in the form of violence against girls and women, has detrimental effects on victims’ wellbeing. Having been directly subjected to abuse or witnessing it as a child, can make one feel disempowered, unworthy, hypervigilant, or find themselves in repeatedly abusive situations as this has been normalised or there are no other safer alternatives. Working in a trauma-informed way encourages curiosity, empathy, and compassion, which often opens difficult conversations and helps victims disclose and get the right support.

6. Domestic abuse can have profound and lasting effects on children. From your experience, what are some of the key psychological and emotional impacts of domestic abuse on infants, and how do you address these issues in your practice?

Josephine: Infants can “give up” on their parents and grow to never really expect that they matter or they give their parents pleasure or pride. Seeing fear or tension in the face of a caregiver, a parent’s mind not able to be in the moment, is very noticeable even to very young babies. Therapy which actively includes both parent and infant can be a very powerful tool (e.g., VIG), and we also run Circle of Security groups across both services, as well as being able to access parent-infant therapy in other services which work alongside.

Panos: Seeing the impact of domestic violence on infants is always very difficult and devastating. Babies who have witnessed domestic violence, especially when this occurs for a prolonged period of time, are left feeling very distraught and frightened. Depending on their internal template and the presence or not of a calming adult to help them make sense of their experience, infants can either become extremely irritable, find it difficult to be soothed or sleep, or, on the other hand, they can “shut down,” avoid eye contact, and turn inwards instead of outwards for soothing. Infant safeguarding is one of the most difficult tasks of our work, and one of the purposes of community perinatal services is really to pick up these risks, help parents find new ways to communicate, lead babies and the abused parent to safety, and prevent parent-child separation by offering bespoke support to everyone involved.

7. What role do you believe mental health professionals should play in addressing domestic abuse, and what strategies have you found effective in supporting those who have experienced DA?

Josephine: First, always ask about it, as it can be hard to acknowledge and impacts people in terms of shame and isolation. Often people are afraid of the involvement of social services, as they mistakenly feel the primary role of social care is to remove children. There are times that education is needed in order to recognise forms of abuse. I have found that incorporating the support and advice of DA specialist third sector organisations is key, as often a more integrated and practical approach is needed in DV situations, alongside psychological therapy.

Panos: In my experience, mental health professionals are often the first ones to be on the receiving end of disclosures of DA. This happens because we tend to be seeing service users for more than one appointment, have a meaningful therapeutic relationship with them, and have the appropriate training to recognise and safeguard victims of DA and their children. A whole system approach is key, and wrap-around services, particularly for women, are very important for effective interventions. Of course, there is still a lot that needs to happen for populations who are marginalised, like justice-involved women, homeless people, and people from the LGBTQ+ community.

8. You emphasise the importance of the therapeutic relationship in facilitating growth and change. The therapeutic relationship is also central to our programme, For Baby’s Sake, and we believe that relationships can heal relationships. How do you build and maintain a strong therapeutic alliance with your clients?

Josephine: By being genuine, warm, and human, and taking the time to listen and understand. I agree that the quality of the therapeutic relationship carries more weight than the mode of therapy or treatment. The timing of an intervention needs to make sense to the client.

Panos: This is a very difficult question to answer. Strong therapeutic alliance usually takes time, and a warm, kind, not-knowing stance usually helps the person to feel accepted and see the therapy as a safe space. I guess difficulties arise when service users, due to their own experiences of violence and abuse, get angry with us or are understandably very guarded as we represent perhaps a system that in the past may have failed them or their family members. In these occasions, remaining calm and keeping the communication channels open is important whilst working on any ruptures which may have taken place.

9. Neuroscience has highlighted the critical importance of the first 1001 days of a child’s life. How does this understanding influence your approach to working with young children and their families, and what key interventions do you prioritise during this formative period?

Josephine: The ameliorative effect of attuned and sensitive parenting is well documented, and so this is a priority. Seeing a family in person as well as being flexible about online sessions is helpful. Helping people to feel bonded with their babies and being able to recognise the baby’s communications to facilitate the development of a relaxed and enjoyable relationship. This involves playing together and can include direct therapeutic involvement in key moments of the day. There are particularly stressful phases for most parents when interventions can be more targeted, like teething, weaning, and learning to sleep. However, many ordinary events may present difficulties for parents in terms of “ghosts in the nursery,” i.e., their own childhood experiences.

Panos: Developments in affective neuroscience and rigorous research in the early years have given us lots of information and tools to better support parents and babies in this formative period. Research on foetal brain development, the role of epigenetics, and the intergenerational transmission of trauma have given us incredible insights on how important and cost-effective preventative work is in the perinatal period. One of our main priorities during this period is to support the baby’s primary caregiver’s mental health with bespoke interventions, to ensure the family has access to social support like health visiting, community groups, and peer support spaces, and finally, to ensure the babies have the opportunity to play. Play is linked with so many benefits for brain and social skills development.

10. As two clinicians with varying levels of experience in the public mental health sector, what are your hopes and aspirations in the field of perinatal mental health?

Josephine: Ongoing resourcing! Perinatal services must not be determined by where a person lives, but rather by what they need. It is wonderful that there has been a great deal of investment in perinatal services over the last ten years, and we are growing a diverse and highly trained workforce to help inform and strengthen the network. However, many services are still evolving. Even in our five boroughs, there are differences in the provision of parent-infant psychotherapy and psychological interventions for people who have had children removed through care proceedings. There are still differences in who can be seen and for how long. Maple recently changed their access criteria regarding perinatal loss, i.e., recognizing that a loss for whatever reason in the perinatal period can remain a significant issue years later, and we are also now open to self-referrals. I would like to see services integrate fathers and partners more and for there to be more conducive working spaces available for us to provide therapy.

Panos: Seeing access to perinatal specialist support becoming the norm for everyone, regardless of ethnicity, gender identity, class, or sexual orientation, is one of the things I hope will improve in the future. I also hope babies’ voices will be represented in policies, laws, and service design both in the NHS and beyond. Not everyone will require a specialist mental health team when they get pregnant and have a baby, but those who do should feel that they know where to find it, that they will be seen promptly, and will not be put off by stigma or the fear of social care involvement. We still have a long way to go, but I believe we are on the right track thanks to the efforts of parents with lived experience and advocacy groups who have done so much work over the last years in the UK.

Information about the NLMHP Perinatal and Maternal Mental Health Services

The North London Mental Health Partners (NLMHP) Maple Service  is a community-based psychological therapy service. The Maple Service is a dedicated team of clinical/counselling psychologists and a peer support worker (someone with lived experience of birth-related trauma). The service offers comprehensive assessment and therapeutic support to people whose level of distress is significantly interfering with their quality of life. Distress may be related to the following areas: 1. Fear of childbirth (tokophobia), Birth trauma: this may be directly experienced or witnessed, 2. Pregnancy loss: associated with fertility treatment, miscarriage, termination or due to a serious medical condition, 3. Stillbirth or death of a baby, 4. Loss of a child due to social care proceedings: This includes working with parents whose babies under 18 months have gone into care or when an unborn child may go into care at birth. For people who have experienced a perinatal loss or loss of a baby due to social care procedures, it doesn’t matter how long ago the loss occurred, they can still access Maple if they are currently experiencing difficulties primarily related to it.

The NLMHP Specialist Perinatal Mental Health Service (SPMHS), is a community based mental health service providing specialist assessment and treatment for women and birthing people with mental health difficulties who are planning a pregnancy and need advice, are currently pregnant, have had a baby in the past 13 months (with follow-up for up to 24 months) The service consists of core members of the multidisciplinary team including Psychiatrists, Clinical Psychologists, Nurses, Occupational Therapists, Nursery Nurses, Administrators and Peer Support Workers. Through a biopsychosocial approach, the service helps families affected by a new or pre-existing parental diagnosis of serious mental illness.  The team offers one off assessments, psycho-education and advice, assessment and information about other services. Those women with severe mental health difficulties such as Complex Trauma, Bipolar Affective Disorder and Schizophrenia may have longer term interventions under our service.

Assessment, advice and treatment may be in collaboration with the woman’s usual psychiatric team where she has one, and alongside the midwifery and obstetric teams.

Comprehensive medication advice is available for those with mental illness on psychiatric medications who are planning a pregnancy, are pregnant or breast feeding.

The team supports mothers in developing a healthy relationship with their infants, thus reducing the impact of maternal mental illness on child development. They also encourage the involvement of fathers or partners in the process.

Both services work closely with hospitals, primary and secondary care mental health teams within the NCL catchment area ( Boroughs of Barnet, Camden, Enfield, Haringey and Islington), and third-sector organizations. The following clinicians can refer to this service: GPs, health and social care professionals, community psychiatrists, obstetricians, midwives, health visitors and social workers. The services are also currently developing a self-referral pathway.

For further information or to make a referral, contact nlft.ncl.perinatal@nhs.net