ADAPT: Healthy relationships clinical adaptation

We’re working with 11 FNP sites from around the country and Dartington Service Design Lab (DSDL) to co-design a number of adaptations to the FNP programme which we will put through rapid-cycle testing over the next year. The ADAPT project (Accelerated Design and Rapid Programme Testing), is part of the wider FNP Next Steps programme.

In the fifth of our clinical adaptations blog series, Kathleen Cruise, Supervisor of the Lewisham team, outlines the adaptation they’re developing. Their focus is on healthy relationships and the benefits of growing up around sensitive parenting.

Lewisham has one of the highest rates of domestic abuse in England. Thirty four per cent of FNP clients in the borough have been abused by someone close to them and many grow up in families where domestic abuse occurs. And, even in households where there has not been any domestic abuse, the risk of it occurring during pregnancy and the first year after giving birth is increased. This is a period when the FNP team is most involved with families, meaning we’re well placed to help make positive changes.

Evidence shows that domestic violence is strongly associated with high levels of perinatal depression, anxiety, and post-traumatic stress disorder in mothers. Living in a household where domestic violence happens can also have a major impact on a child’s mental, emotional and psychological health, as well as their social and educational development. Research suggests that children who are exposed to violence are more likely to become abusers or victims themselves later in life, and the effects are more severe the longer they’re exposed. Effects can include: lack of respect for the non-violent parent; loss of self-confidence (affecting their ability to form relationships in the future); being over-protective of a parent; or behaving violently themselves. Breaking the cycle of abuse is therefore vital.

Lewisham’s adaptation

Due to the prevalence of domestic violence in Lewisham, and the huge trauma it causes many families we work with, we decided very early that healthy relationships would be our focus in ADAPT.

Our adaptation focuses on the benefits for children growing up in a family able to manage conflict and offer sensitive, responsive parenting. The adaptation explores how abusive and controlling relationships can damage a child’s development and emotional wellbeing. A key component of the adaptation is improving parents’ awareness of how important the way they interact with their baby, and each other, is in their child’s development. Clients are offered the adaptation during a targeted home visit in each phase of the FNP programme, according to their needs and situation.

We have introduced new materials and created two toolkits to use with clients to explore what a healthy relationship is; to raise awareness and understanding of what constitutes an abusive relationship; and the effects of both types of intimate partner relationships on a child.

The core toolkit we use with all clients includes key components of the existing programme as well as some of the new facilitators we’ve introduced. One facilitator, ‘Through the eyes of a child’, can be used from pregnancy through to toddlerhood to help clients understand how a healthy relationship looks to a child and how an unhealthy relationships can make a child feel.

In the individualised toolkit we use for cases where we’ve identified domestic violence as an issue, we use themed programme facilitators to make the client aware of the positives of healthy relationships, but also to expose the negative impact of unhealthy relationships. Where appropriate, we also refer families to specialist services for those identified as suffering abuse or who are at risk of abuse.

To help deliver this adaptation, our family nurses received two days training from the Tavistock Centre on working with domestic abuse relationships, in addition to a day’s training on Mindfulness, to help them manage these situations to the best of their ability.

Designing new materials

We tried a number of different designs for new resources to avoid them being either patronising or blaming, keeping in mind that all relationships are complex and multi-faceted. It was challenging to create materials to fit each situation, so we decided to bring together a number that could be used in both toolkits. We also adapted a relationship questionnaire and used this as the assessment, along with our clinical judgment, as to what intervention was most appropriate for each client

Before using our adaptation, we asked each client if they felt that addressing domestic violence was appropriate during visits, and they overwhelmingly agreed that it was. We shared with them some of the early designs for new materials which they commented on, allowing us to make changes to ensure they would work well. As we developed the adaptation, we listened to what our clients liked and we added some ideas to our core pack of materials.

Celebrating client’s strengths and accessing further support

Intimate partner violence can be difficult to discuss with clients who are already in an abusive relationship, particularly when focusing on how it affects a child, so we included materials celebrating a client’s strengths in the core pack to remind our clients that they are doing a good job in very difficult circumstances. We were mindful that any intervention we did should not cause harm – research told us that expert services were essential in supporting women who were affected by controlling, violent abuse. Therefore our role would be identifying and referring women to specialist services, whilst also continuing to support them in their role as a parent.

We know that sensitive and responsive parenting is the most beneficial start a child can have in life, and parents free from worrying about abuse/violence are more likely to have the emotional energy to parent their child in this way. Our young parents are important and are doing a great job raising their children in a safe and nurturing way.