26th October 2021
Case study: The health visitor as the ‘key worker’: leading, coordinating and providing support for perinatal anxiety and depression during a pandemic with multiple interventions across the skill-mix team
We are delighted to share a case study written by Alice Gibson, a specialist Health Visitor (HV) in Perinatal and Infant Mental Health at Central London Community Health care NHS Trust. Alice’s case study showcases the HV’s role as the ‘key worker’ applying her specialist public health nursing skills to improve outcomes for the whole family.
All names have been changed to protect client confidentiality.
This case study illustrates the vital role of health visitors (HVs) in supporting families who are experiencing perinatal mental health problems. HVs promote good mental health and wellbeing for the whole family, identify problems early, and deliver evidenced-based interventions to improve outcomes.
This case study demonstrates how, during the pandemic, a range of treatment options and methods were used to support a family, including interventions online and face-to-face contacts. The HV worked with the family to ensure that they received a personalised package of support using a multi-skilled approach, invoking the help of colleagues from a variety of professional backgrounds within a skill-mix team. The response to treatment was reviewed regularly and used to inform future care. Getting the right help made a big difference to the whole family.
During a a routine new birth visit, the HV noted that a mother (Rose) was having difficulties coping with her newborn baby (Alex). This was beginning to affect her mood. Rose’s HV is highly trained and skilled in identifying mental health problems and, through completion of a health needs assessment, was able to detect subtle and early warning signs of perinatal mental illness.
Alex was a very much wanted baby, conceived through IVF. Rose, now 42, had suffered a previous miscarriage and so, throughout this pregnancy, had been fearful of losing her unborn child. The pandemic exacerbated her anxiety as she had to cope with shielding and the knock-on effect of social isolation during pregnancy and after the birth. To add to this, both Rose and her husband’s family lived abroad, increasing her sense of loneliness and lack of support.
Rose was from a high-achieving professional background. Lacking a local support network, she depended increasingly on her husband who was trying to work full time from home. When Rose’s HV identified early warning signs of perinatal mental illness, Rose was offered additional support from myself, the Specialist HV for Perinatal Mental Health. Rose perceived herself as an older first-time mother ‘who should know how to cope’ and seemed resistant to accepting additional support. In hindsight, she told me that she had a fear of being judged by professionals and felt very guilty for not being able to enjoy her baby as expected. Through building a trusting relationship, Rose disclosed she had a history of chronic anxiety and low mood. This had remained unknown until her mood deteriorated after the birth.
Having a baby is a life changing event and it can trigger mental health problems experienced in the past. If I had known about Rose’s previous history, support could have started during pregnancy which can help parents to make plans about the best way to manage their mental health during the perinatal period. Rose felt a lot of pressure to be ‘happy’ and had some unrealistic expectations of herself which could have been modified before her baby was born.
Following the face-to-face assessment, I began a series of virtual contacts (due to the restrictions of the pandemic) to provide enhanced listening visits which are therapeutic visits to support mothers with mild to moderate perinatal mental illness. In line with NICE guidance (2016), I undertook a guided conversation to explore Rose’s mental health and used clinical assessment tools which indicated significant low mood, and high levels of anxiety.
Rose was tearful, insisting her baby was ‘perfect’ (a theme she repeated to several health professionals) whilst at the same time seeking help from a paediatrician privately. This left her feeling all the more inadequate at her perceived ‘failure’ to successfully soothe Alex who was often observed to be irritable and unsettled. This aggravated her negative emotions such as feelings of worthlessness and being generally overwhelmed, which led to her withdrawing from contact with friends and family. In addition, she was becoming hypervigilant, constantly checking up on her baby, and took him to A&E several times. It was clear that Rose needed access to specialist intervention to prevent further deterioration of her mental health. At this point, I referred her to the Perinatal Mental Health Team, and Rose was assessed by the consultant perinatal psychiatrist who continues to treat her mental illness.
In partnership with Rose and her family, we developed a supportive care plan. My focus was using listening visits to help Rose explore underlying factors which were causing her anxiety and to help her better understand normal infant development, develop more realistic expectations, and grow in confidence of her parenting abilities. Over time, we moved from meeting virtually to meeting face-to-face (without PPE) at Rose’s request, walking around her neighbourhood whilst she talked, and I listened. This provided outside contact for Rose, structure to her day, exercise, and enabled me to observe parent-infant interaction at the same time as further strengthening our relationship.
The trusting relationship Rose and I had made had helped to increase Rose’s confidence to a place where Rose felt able to participate in Talking Times, which is an evidence-based group invention using a Cognitive Behavioural Therapy (CBT) approach that I facilitate for women with perinatal mental illness and their babies. The group provides opportunities to practise self-help strategies and meet other women who have experienced the same difficulties during their parenting journey. Due to the pandemic, I have been delivering this group virtually using a modified programme over six weeks. The effectiveness of the group rests on my ability to build a trusting relationship with the women who attend, but also to create an environment whereby they can build relationships with each other and provide mutual support. This is more challenging using virtual methods, but as we all gain experience of remote interactions this has proved not only possible, but welcomed, by the women who attended these groups during lockdown.
Rose also benefitted from the wider support of the multi-disciplinary team as part of her support package including:
- Community Nursery Nurse (CNN)
Rose shared with me that she was really worried about introducing solid foods to Alex. I highlighted how a CNN could support her with this next stage in her baby’s life. With Rose’s agreement I made a referral. The CNN offered anticipatory guidance and support with introducing solid foods, which eased Rose’s anxiety about this new stage considerably.
- Music Therapy
Rose and I explored together other opportunities to help her relax and strengthen her relationship with Alex. In partnership with Rose, I made a referral to Melodies for Motherhood, which is a musical intervention run by an organisation called Breathe, specifically for women with perinatal mental illness and their babies. This also proved to be very successful.
Outcome and Impact
Rose’s depression improved whilst her anxiety levels remained high for some time. Clinical assessment tools, used alongside guided conversations, enabled focus with regular opportunities for Rose to explore how she was feeling and to visually see the progress she had made. Most importantly, I was able to show Rose objective evidence of her improvement over time, and this led into discussions around how these gains could be maintained. Rose is recovering gradually and beginning to think about returning to her professional life. Rose is enjoying her family, is responsive to Alex and is coping well despite the daily complexities caused by the pandemic. Alex is thriving, happy, confident and is developing well. The family is working towards being ‘stepped down’ to access care through universal services, which will certainly reduce the need for Rose to use more specialist services, including the GP and A&E.
“The help, care, and guidance offered (by the HV team) has been exemplary.”
Regarding the Talking Times group, her evaluation states:
“I have found attending the group so helpful and now feel really hopeful about the future. Just knowing that you aren’t suffering alone makes all the difference.”
Lessons learned and recommendations
- Strong and trusting relationships across professionals and families are the core values of health visiting. They enable us to overcome the initial reluctance and resistance we frequently encounter when parents are afraid to reach out and ‘ask for help’. By delivering good collaborative care, in partnership with parents, we can achieve the best outcomes possible.
- Consider referring ANTENATALLY to Perinatal Mental Health Team, or specialist HV, any expectant parents with a history of perinatal illness or previous low mood, anxiety or miscarriage.
- A multi-pronged intervention approach can maximise impact and skills of the wider team. This may involve a health visitor, Specialist HV, psychiatrist, music therapist and CNN, all making significant contributions, in addition to medication where appropriate.
- Listening visits and group work can be successfully delivered to some parents online. However, virtual methods do have recognised limitations for assessments and require more time and new skills, and for there to be a trusting relationship between the parent and the HV.
- Face-to-face contact has many benefits and could still be attained even during the pandemic restrictions. We met outside and walked and talked together which avoided the barrier of PPE and brought multiple benefits.
- Meeting other women in a group where they can all feel safe to share experiences is a powerful tool to counter isolation, provide mutual support and increase parents’ understanding of perinatal mental illness.
- The role of the HV as the ‘Key worker’ and ‘care coordinator’ was central to the successful outcomes for this family; sensitively reaching out to other professionals through careful exploration and collaboration with the parent. This enabled an effective ‘team around the family’ approach, with the HV as the lead professional for other professionals working with the family.
Alice has been working as a specialist HV for perinatal and infant mental health for the last 14 years and says:
“Although the work can be challenging and is often emotionally demanding, knowing that you can make a difference by supporting families at a critical time and helping mothers to access timely interventions so that they can start to harness hope, recover and enjoy their babies is incredibly rewarding.”
We would like to say a heartfelt thank you to Alice for taking the time out of her busy day to write such a brilliant case study which raises the profile of health visiting and supports the #TurnOffTheTaps campaign.