Cognitive behavioural therapy techniques helped to create a postnatal depression support group that improved self-esteem and made mothers feel safe and supported
Postnatal depression can have serious implications for mother/child bonding and damage relationships between parents. Approaches to treat it need to overcome barriers that have led to high attrition in some group or clinic-based postnatal depression treatment studies.
This retrospective evaluation explored the benefits of offering postnatally depressed mothers group support based on cognitive behavioural therapy. It helped to improve women’s self-esteem and self-worth and to make them feel safe and supported.
Citation: Alexander P (2013) CBT-based support groups for postnatal depression. Nursing Times; 109: 41, 12-14.
Author: Pat Alexander is a senior health visitor and community practice teacher at South Essex Partnership Trust.
- This article has been double-blind peer reviewed
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Postnatal depression has serious implications for mother/child bonding (Bowlby, 1951) and is detrimental to relationships between parents (Bancroft and Ardley, 2008).
New approaches to postnatal depression treatment need to overcome barriers to it such as stigma, lack of transport and childcare, and high attrition rates that have been found in some group or clinic-based postnatal depression treatment studies (Dennis and Hodnett, 2009).
A course of six group sessions were set up by a charity, which invited representatives of the NHS to work with it in addressing the needs of mothers with postnatal depression. The framework for the sessions was created by two health visitors, one undergoing further training to become a CBT therapist and the second who had counselling experience.
The framework relied heavily on Milgrom et al’s (2006) work relating to using CBT principles to work with postnatally depressed women in community groups, and the compassion-focused work of Gilbert (2006).
All referrals to the support group came from health visitors and were directed through the charity, which managed the project’s administration.
The following gives an insight into how compassionate CBT is used in the group sessions and at individual contacts outside the weekly meetings.
Each woman receives a home visit before joining a new course, and is given a letter offering information about it. She is reassured by the facilitator that she will be cared for and listened to but if she wishes to remain silent, that is acceptable too.
We explain that a taxi will be provided if she has no transport and that a creche is available. We also promise that we will be there at the main entrance to welcome her on the first day as many mothers feel isolated, frightened and vulnerable at this time.
Each mother is telephoned the day before the course starts to help her feel that her presence is valued and to offer an opportunity to discuss any concerns she may be experiencing. These phone calls continue throughout the course between each session. This approach helps the facilitators to build a relationship of trust with each group member.
These simple actions help the women to feel safe and protected and challenge any entrenched negative beliefs they hold in relation to their self-worth.
The use of language
The language used in the sessions is accepting and non-judgemental. When group members express negative thoughts or emotions, these are listened to and acknowledged before being explored by the wider group, with the permission of the individual concerned. In this way, positive elements such as courage, perseverance and dedication are recognised, increasing the women’s self-esteem through peer support.
During all sessions the word “we” is used in place of “you”. This language helps to unite the facilitators and group members and bring a sense of wholeness to the sessions. We also regularly use the term “I’m doing the best I can” to soften the self-critical thoughts of “I am a failure” or “I’m not good enough” and to address perfectionist tendencies gradually.
Language is kept uncomplicated to be accessible to all group members. Educational aids are restricted to a flip chart to maintain simplicity and spontaneity.
The group feed back each week on their experience of doing or trying to do any tasks they have been set between sessions. Facilitators are set the same tasks and feed back to group members; this approach helps to minimise the “them and us” divide and encourage group members to share their experiences and thoughts.
Session one is often emotional as we look at experiences before, during and after birth and the expectations of the mother during this time. During this session, most group members begin to realise they are not alone. The need for gentleness, acceptance and valuing is crucial as we acknowledge and explore negative emotions. We use words such as “walking the path together” and talk of the “uniqueness” of each member present to help develop a sense of belonging to the group.
Our homework following the first session is for the mothers to try to carry out one small activity that they used to find pleasurable. This ends the session on a positive note.
Session two involves looking at the relationship between thoughts and behaviour. We use a simple role play to create an awareness of how individuals react to the same situation in different ways depending on their state of mind. This awareness is then accompanied by looking at the depressive spiral and how we can develop tools to help prevent ourselves from becoming depressed. These techniques could include speaking to friends or reassuring yourself. The compassionate element of “being kind or gentle to ourselves” is a philosophy that underpins every session and the facilitators offer personal examples to demonstrate this where appropriate.
Sessions three to five involve the recognition of stress within ourselves, followed by basic relaxation techniques. Role play is used to demonstrate assertiveness, aggression and passiveness using everyday examples from motherhood and the use of a positive data log, which we call “my book” in session.
The positive data log, carried out during the fifth session, continues to build on the compassionate CBT approach and to challenge low self-esteem. Each group member has a personalised note book that is passed to other members of the group so they can write a few words to describe what they like about the person. The completed notebooks are returned to their owners and taken home to be read. The contents of the notebooks remain private to each individual. Feedback from past groups has shown that this exercise creates feelings of being soothed and safe. For some mothers, these words are the only written form of praise or friendliness they have ever received. The mothers are encouraged to continue to use this notebook at home to write positive notes, and it becomes a part of their toolkit to prevent low mood.
At the sixth and final group session, further support is offered in a variety of ways, such as a reunion after the sessions are over, a home visiting volunteer, attendance at family group or the option to make arrangements for one-to-one counselling.
We used an evaluation form to collect qualitative data at the final session of each group. The form included general questions phrased both positively and negatively to offer a reasonable balance and to reduce “acquiescence bias”, where participants have a tendency to agree regardless of the question’s intent.
In total, 30 questionnaires were collected, leading to 13 themes being identified relating to feelings and thoughts. These themes were classified further under three topic areas:
- Low self-esteem;
- Positive feelings;
Table 1 offers a detailed picture of the responses received.
Feedback from the completed questionnaires (Table 1) showed that 50% of the participants were experiencing feelings of loneliness, depression and tearfulness and 37% expressed a fear of speaking out.
The Department of Health (2010) refers to the importance of feeling cared for and considers compassion to be a vital elements of positive patient care. Compassion, which Gilbert (2006) describes as “an element of loving-kindness”, is viewed by Eastern traditions as central to freeing the mind from the power of destructive emotions such as fear, anger, envy and vengeance (Goleman, 2004). It was therefore interesting to note the effect the compassionate-focused CBT group had on the women attending.
The following quotes have been extracted from the participants’ responses to the questionnaires.
Kindness to self:
“Coming to the course has helped me be gentle with myself.”
Kindness from others:
“It’s nice when someone actually cares about our feelings, makes us feel worthy.”
Kindness to others:
“This course is wonderful. I hope many others benefit from it in the future.”
In addition to the theme of kindness, participants expressed coming to terms with their feelings and an increased ability to have fun and enjoy friendships.
“I have been laughing and smiling so much more and noticing and enjoying things a lot more.”
“Now the course is finishing I will be friends with these lovely ladies.”
Gilbert (2006) describes how the feelings associated with offering compassion can counter feelings of isolation.
The participants also remarked on how the course helped them to learn about themselves and others.
“Coming to the course has helped me be understanding towards others.”
“Coming to the course has made me feel happy about myself.”
“Now the course is finishing I will remember to use some of the tools that I learnt about when I most need them.”
These expressions of awareness and empowerment show participants benefitted in both the short and the long term from the group, by learning to look to the future and use learnt techniques to deal with life stressors as they arise.
The findings in this evaluative study suggest that CBT-based support groups can be effective in alleviating the symptoms of postnatal depression and teaching long-term coping strategies. Evaluation showed a focus on compassion enabled group members to develop self-kindness and experience the feeling of being cared for.
The elements of the course (Fig 1) are supported by the demands of recent government reports. For example, by offering early targeted support for emotional and mental health problems in the postnatal period, we are helping children to have a good start in life (Cabinet Office, 2006). This supports the long-term aim of setting up similar groups elsewhere in the UK.
Recommendations for practice
Due to the group’s anonymity, it has not been possible to carry out follow-up contact to identity long-term benefits. It would be helpful to run future groups with follow-up as part of the study so that this could be explored.
We also feel it would be beneficial, in view of the recognised problem of paternal depression, to offer support to the partners of postnatally depressed mothers (Bancroft and Ardley, 2008). Milgrom et al (2006) offers an outline of a programme to include fathers in a couples’ support group that could serve as a helpful template for partner involvement in the future. The 2012 support groups have incorporated two evening sessions that partners can attend separately.
This evaluative study only involved postnatally depressed women and it may be useful to broaden support in the future to include the antenatal period, adopting a compassion-focused approach in an individual or a group setting.
- Postnatal depression can have a detrimental effect on mother and child bonding
- CBT-based support groups can help to alleviate the postnatal depression and teach long-term coping strategies
- CBT techniques can help patients to recognise the relationship between thoughts and behaviours
- Extending warmth and acceptance to others helps to reduce people’s own feelings of isolation
- Fathers also experience postnatal depression and may benefit from similar approaches
Julie Teatheredge my amazing mentor and guide from dissertation to publication; Helen Elia (Health Visitor) and the Home-Start charity without whom the group would not have been born or be continuing.
Bancroft PR, Ardley LB (2008) Major Depression in Women. New York, NY: Nova Science Publishers.
Bowlby J (1951) Maternal Care and Mental Health. World Health Organization Monograph (serial no 2). Geneva: WHO.
Cabinet Office (2006) Reaching Out - an Action Plan on Social Exclusion. London: Stationery Office.
Dennis C-L, Hodnett E (2009) Psychosocial and psychological interventions for treating postpartum depression. Cochrane Library; 3.
Department of Health (2010) Transparency in Outcomes - a Framework for the NHS. London: DH.
Gilbert P (2006) Compassion. Sussex: Routledge.
Goleman D (2004) Destructive Emotions and How We Can Overcome Them. London: Bloomsbury Publishing.
Milgrom J et al (2006) Treating Postnatal Depression: a Psychological Approach for Health Care Practitioners. Chichester: John Wiley and Sons.